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w--,, APPLICATION FOR PERMIT <br /> .` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES i <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N S9Id%J20�9INSTPHONE <br /> OCgTON(2CA)95201420 Jt b <br /> P O BO ,gfa86rZ4-7.5 igSZ5, <br /> PERMIT EXPIRES JYEAR F&QM DATE ISSMIM <br /> �(Cqete in Triplicate) <br /> ie here made:to San Joaquin counta permit to construct rind/or in* <br /> theeRules andeRegulitionsin dof Sans <br /> Appllcatio by i and <br /> application is made in Ceatp3iance with San Joaquin County Ordinance No. 51+9 and 18 <br /> Joaquin County Public Ifela Services. <br /> City Lot Size/Acreage <br /> Job Address <br /> Phone <br /> Owner's Name qmryls Address ZSo n' <br /> y �f ddress VVNIqlLt-6-h.License No. 1Z=7— Phone <br /> Gontractor" Jar <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ <br /> SYSTEM REPAIR ❑ OTHER <br /> PUMIP INSTALLATION ❑ DISPOSAL FLD. $�4 <br /> k TANK ���. SEWER LINES �---- <br /> A ST: SEPT C <br /> E 70 NEA E <br /> DISTANC. --- <br /> FOUNDATION -- AGRICULTURE WELL OTHER WELL <br /> 3 <br /> INTEN�DEb USE _TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> petro c !sf T5 <br /> ❑ Manteca Dia. of Well Excavation <br /> n Industrisi ❑ Open Bottom _ <br /> ' Type of Casing f <br /> ��n�✓1 <br /> Ci Domestic/Private LI Griavek Pack ❑ Tracy Depth of Grout Seal '�°S <br /> I"1 Public " !1 Oi <br />