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APPLICATION <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION u SPONSAN <br /> BOX 2009, STOCKTON, CA 95201 COPY <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to SJoaquin County for a permit to construct and/or install the vork herein described. This <br /> application is mile in compliance <br /> oa <br /> liance with San Joaquin County Ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. _`'SY_ , <br /> Job Address `1100N � k �1� crv` Kt61 Lot <br /> �Size/Acreage <br /> Owner's NamaLF`tNV�nl t,!a% Address �nF,..�R�cZ'�\ gr�rNF.I, � "�,..�.,,.ih,�oneq — \ <br /> Contractor ress`.�\! R ZQ*1kSn- y) "'� iicee0nse No.�ligLb Phone `�J <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT n DESTRUCTION ❑ Out of Service Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERX�/Monitori� ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK �������,��,� ,,,///¢¢[yyy� SEWER LINES 1&6 DISPOSAL FLD. PROP. LIN <br /> FOUNDATION AGRICULTURE WELL � OTHER WELL N PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Opan Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Ll Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing_ A41A / Specifications <br /> Il Public tl Other 11 Delta Depth of Grout Seal A7 Type of Grout <br /> I I Irrigation _Approx. Depth vq Eastern Surface Seal Installed by 42&&U <br /> Repair Work Done L3 Type of Pump vIff H.P. tate Work Done_ <br /> Well Destruction ❑ Well Diameter /V/1-1 Sealing Material i Depth <br /> Depth Nle Filler Material i Depth f-7- <br /> 7 <br /> 1322 <br /> GEOLOGICAL AUDIT SERVICES, INC. <br /> 1803 W. MARCH LN., STE. A 209-956-0264 <br /> STOCKTON, CA 95207 <br /> <br /> 19 <br /> PAY IS <br /> TO THE <br /> ORDER OF <br /> LLARS <br /> C LEGE SOUARE OFFICE <br /> WELLS F"GO BANK <br /> 1015 WEST MARCH UNE.STOCKTON.CA 95207 t r <br /> FO f SlIS • O Usk ,� � 9�E-cs gl�-oa <br /> uAny <br /> <br /> Gm ulwe ins Vwmny: r wlu,y"Arri rn DW penuN r,ar6v lir the ww lur when Inia per ma Is Ufueo, I anal)emppuy persons eunlect to Worxman a corupanaa' <br /> tion laws of California." <br /> The applican at c Yfor a squired in!R!Stiocx. Complete drawing on reverse side. <br /> Signed Title: �.�li���fNl1/IDQ� Data: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 <br /> FEC I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> EH1321 IaEV.I/n 51 <br /> EH 11 2a <br />