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SAN J09QUIN COUNTY PUBLIC HEALTH PnVICES <br /> WWIRONMENTAL HEALTH DIVISI <br /> 445 A SAN JOAQUIN, PHONE (209)463=3420 <br /> P 0 HO% 2009E STOCKTON, CA 95201 <br /> P,, WIT EIIIIRES YEAR FROM DATE ISSUED <br /> (Complete 1n Triplicate) <br /> Application to hereby wde,to Baa Joaquin county for s pertatt to constr4ct and/or install the work herein described. This <br /> application is Sade 1a ccapltance with Bea Joaquin county prdinance.No. ;t4 and 1562 and the Rules and Regulations of Ban <br /> Joaquin county Publtc Yeelth Barylces. <br /> Job Address o11D3 ('n1IhtYU 61 Jd ary tC - th., Lot size/Acreage IDo' X IZA <br /> CA <br /> Owns(? N.rne PheuYOn USW {?ralus <br /> C� Co Address aU10 IM1no X(l <br /> It[Lfyloyt �&FI PhoneeYn610-&2-95DO <br /> GY r- 6we"d,Cw <br /> Contractor n Address 14057 fors! Chs6nclo Hwy License No. U34343 Phone !0 - '71-Z3a'7 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION ❑ Out of 80rvics Well ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 Monitoring Well LT <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ DISPOSAL FLD. PROP. LINE _ <br /> FOUNDATION AGRICULTURE WELL . OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> Ll Industrial ❑ Dpon Bottom O Manteca Dia, o1 well Escavetio d 0* of Well Casing a `� <br /> r1 Domestic/Private V Gravel Pack ❑ Tracy Type of Caning_— PVC SpeciliSation{ <br /> Il Pudic ll Othof n Delta Depth of Grout Seal x I J I Type of Grout "01,1 <br /> I I INIUahon EO Apggs. Depth I I Eastern SuAaea Soei Installed by <br /> Repair Work Done 0 Typo pf.Pwrnp H.P. _. Stato Work Done <br /> War Datfuctign ❑ WOR D4meter Sealing NaNrial F Depth <br /> Depth Filler Notarial b Depth <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION I I INo septic system permitted if public fewer is <br /> available within 200 faet..l <br /> Inoto4pian wdl verve; Rootince _ Cgrn"rcial _ Other <br /> Nun"911 g+'w'Y phhr, .• NYMOr of b0mrrts <br /> ChorgGW al wo tg a Itoplh of 3 toot: - Witter lobi! depth -... �= <br /> SEPTIC TANK ❑ Typo/Mfg — Capacity— No. Compartrnonto C <br /> PKG. TREATMENT PLT. ❑ <br /> BANK OF NEW ENGLAND,N.A. 73144 513 <br /> UH <br /> GROUNDWATERTECHNOLOGY, INC. BOSTON,MASS ltd <br /> '[-- <br /> Western Region CHECK NO. 000731.44 <br /> 4057 Port Chicago Highway <br /> Concord, CA 94520 e <br /> 447865 09/02/92 f+s+EaHs9eaEaE1713.00 <br /> PAY VOID IF NOT CASHED IN 60 DAYS <br /> NE HUNDRED SEVENTY EIGHT AND 00/1.00 +Eat*stasasat,>Faex#;'tstit*afaswafatesit**as+tssafw*aeiFasasaaasxit>♦*rt,r*st>r <br /> TO THE ORDER OF <br /> SAN JOARIIJN COUNTY PUBLIC GROUNDWATER TECHNOLOGY,INC. <br /> HEAL_1f-1 DEPT. <br /> P.O. BOX :2009 <br /> STOCKTON, CA 95201 l <br /> By <br /> AUTHORM60 SIGNATURE / <br /> Applicant - Return all copies t0: Ban onmenA County Public health Services <br /> Environmental Health Permit/Services <br /> 998 N Sao Joaquin, P p Box 2009, Btkn, OA 85201 (i <br /> FEE DUE AMOUNT/REMITTED CA//SH RECEIVED oY DATE PERMIT NO <br /> . EN t}SI IREV.U. �� C/ � / �� J/t/ , 1 • 92 �' zL� <br /> fM q_7• <br /> . Ew ta.2,IRAV.1,s, <br /> fN <br /> 430 . <br />