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APPLICATION FOR PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMEtfTAL HEALTH DIVISION <br /> 1601 E. HAZELTON AVE. , PHONE (209)468-3420 <br /> P O BOX 2009, STOCKTON. CA 95201 <br /> PERMIT RZPIRR4 1 YRAR FROM DATE ISSUED_ <br /> (Complete in Triplicate) <br /> Aypllcatiam is hereby Inds to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application to mads to conpusace with Sea Joaquin County Ordinance No. 519 and 1862 and the Rules and Regulations of San <br /> Jamgttta Comety Public Health Services. //�� <br /> Job Address -T7 4,.�,Aes ATa City [ 4 Lot Size/Acreage Ar-, <br /> Ow w•s Narwa �1 —v c•� �'� Addrea J Phone <br /> Centattor 4 Address License No, Phone <br /> F WELL/PUMP NEW WELL ❑ WELL REPLACEMENT DESTRUCTION Cl Out of Service well L <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C OTHER C Monitoring Mell n <br /> DtfTANCI TO NFA_REST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL MTS/SUMPS <br /> W""DID Ufa TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ' n htdtrMrM ❑OOsn Bona," ❑Manteca Dia.of Well Eacswatwn Dia.of Well Ca" <br /> (1 ower«+•/Prlsalm 0 Oraysl Pees O Tracy Type of CnwV Spscnccabons <br /> 1'1 Pt1EEs fl Dow n Dots Depth of Grow Seal Type of Grow — <br /> I 1 brlpwrn . Appose. Depth I I toNam Surface Seal Installed by <br /> f1spo Walk Dawai U Type sf Ptwttp H P. Seta Wort Dons <br /> WM Dowmesw (3 Wel DWwww Sealing Material • Depth <br /> j filler latartal & Dayth .p <br /> R o.M <br /> K: NEW IfefTAll.ATION e< REPANt/A0p1T1iN1 1 I DESTRUCTION 1 I IRs septic Mtarri pwrrwte0 d prbhc sewer is <br /> evedeble vAthn 200 feat.) <br /> bewto n 00 am. Ro+dMtes!' Cowwnwcld_ other <br /> MAi~M N111V wwk_� write..of beWooms <br /> ownw a1 no M•depIA of S Mal: .d AQQE Wet«table dep I <br /> 110171E Tf1i411 G• TIipMMMB _ Eak L CepannY '06(dgwG-- .No.Campaltmw" <br /> pft To""Aw KT.O ` r MAaaiod Of Oispwsf Z <br /> OMaawas le haemal: YIM..�'� _Foundaliw+la,-T Property Line <br /> ` LtACH"Uwe Ll Nb.B LwtvW W on" '90 FT Toler)length/size 4P711100 110 O olmwsa a 04 w <br /> MR vYwl,'£Q r FndNWn� Prower Lina�T <br /> /10YlOt F1T1 1 I D@Pk 62 drf- Slag r Ww"1»r <br /> Oblwra as its Nee Wo 2Q'L'r Fotrtdation 1 G fT Ptopany Line <br /> 111010111111411,4$MV V Mr 1 he"ommood this apseowten and ow the work wra be oono in eccordancs with Sen Joewim county ordinances.stat.19wa.sod <br /> 010111 fW raB10u1Ma Mar Bow JMwr1w C'osmq <br /> MISS swim M borsed avow*srlwws asnttes the folowng:"I COMY thw in tees performance of the welt for vAdch on pwmit M issued.1"rot <br /> ERM"a"gemmae M%aft woo w M M beaw"sublsci In wortrrwr'a cowww+eatwn lwws of Cailorrra."Cootreetors hemp or suacontractnp sap awes <br /> raga sir M4rww4w"I aarldr was M ata p 601non e M tete wow Y for wtocp this"I r issued.I shMl arnpiov tiwsone subta t to tomrkmen's comww%w <br /> dwb ora of Callaaw.I <br /> t <br /> The doom"wtim mal/ar fophM' psallwr. Complsla drawing an reverse side <br /> This: Dow <br /> FOR DEPARTMENT Ufa ONLYAA <br /> �1 / <br /> Appft~wtesptM by Dew_ * Arae W <br /> PM w Orawt Inewomw by Deb_ Fktw Inspw wr :.v <br /> AodimsnO Csmwwnr <br /> Wlesrt - %*Udu all 94p1e0 to, San Joaquin County Public Health <br /> services. arr1ronmental Realth Permit/+Services• <br /> 1601 S. Rsaelton Ave.. P 0 Bos 2UO9. Stocktaa. i:A 95201 <br /> 11 AAa0004T ous AMOUNT REMorTED ASN ItEC[IVEO av OwTE ►twMtf NO. <br /> rN/0 <br /> r. .r <br />