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/ APPL l C:AT 1 UN <br /> SAN JOAQUIN COUNT I PUBLIC HEALTH SERV I CES <br /> ENVIRON KEN TAL :I IE ALTH DIVISION <br /> 445 N SAN JOAQUIN ,, PHONE (209)468-3420 <br />• P O BOX 2009, STOCKTON , CA 95201 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete itl `I'riplicaLe) <br /> Application Is hereby made to San Joaquin County for a permit Lo construct and/or install the work herein described This <br /> application is made in colrgrliance with San Joaquin County Ordinance No 5h9 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health services <br /> /OS�Iu � ra �� IZ�Pr1 City!�r�{�__C)�n�{' Lot size/AL1 eaKr, <br /> Jab Address`` -------- ------ - - <br /> Owner a Name f aN r11- 60i l it _1f0r" — Address f 0 - U lC �_ 7� Etr�Lr}����rj_ Phone � Z--tj � � <br /> /,6 r r-4. <br /> Contractor_(��JY-1 LL' I PJ Addiess36(,-3 dlrL A XiiK :A ` "�-1!Z-Licen5e No �- It] itZ Phone ` 1b � -1f5 <br /> TYPE OF WE NEW WELL WELL REPLACEMENT 11 DESTRUCTION [-1 out of Service well C1 <br /> PUMP INSTALLATION L7 SYSTEM REPAIR Cl OTHER El Monitoring Well <br /> DISTANCE TO NEAREST SEPTIC TANK( ! 000 SEWER LINES _..-ZI"J DISPOSAL FLO 7�Gta PROP LINE <br /> FOUNDATION 71b`� AGRICULTURE WELL 2! y _ OTHER WELL :Z oL�_ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROM EMAREA CONSTRUCTION SPECIFICATIONS_ <br /> f-) Industrial Cl Open 8oltom Ll Manteca 'Dia of Well Ercavaupn . r Ivt t Dia of Well Casing 1rJl 1 <br /> [I Domestic!Private 0 Gravel Pack PC Tracy type of 5pecilicalrons 6 r > c 7 5 G4tyCr <br /> I I Public Id Other I I Delta Depth of Grout SealiType of Grout f`ir,Ers F_rrrA� E <br /> I l IrriUmion q.L Approu Depth I I Eastern SurfaLa Soul Installed by Lt ,/ <br /> tC h-V!1 I' <br /> Repair Work Done Ll Type of Pump H P _ _ Stale Work Done _ <br /> Well Destruction O Well Diameter <br /> Sealing Material i depth <br /> F1 l Iwr mAtnrlwl L TLnth • �r> _l� — 71- r'r <br />. <br /> � 918 372-1434 FIRST' NORTHERN BANK NO 14408 <br /> P0 BOX t t3J OF DIXON <br /> WEST SACRAMENTO CA 95881 WES I SACHAMLN I O, CA 95691 <br /> 90-5i 5 1211 DATE <br /> WALLACE • KUHL 1st ASSOCIATES, INC 01-05-95 <br /> AMOUNT <br /> $89 00 <br /> PAY Eighty nine and nO/100***'F******' <br /> I <br /> TO Sall Joaquin County Public Health Services <br /> THE <br /> i <br /> ORDER ! �, <br /> OF <br /> iiao1. 0,0811■ 1: 121LOS IS61:0S 0L952 71'� <br /> Signed }( Z"_`7 - - Title IFFi�G 1�1! F� Date <br /> f1(,5�,sr I'1)1e_ 6"o-rsr core,,, vurivj <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Data <br /> odditional Comments <br /> Applicant - Return all copies to San Joaquin County public health Services <br /> Environmental Health PErmit/Servicers <br /> 445 N San .Iougirin, P O Box 2009, Stan, CA 95201 <br /> u3 4 !NFO AMOUNT DUE AMOUNT REMITTED fIy� S11- RECEIVED BY 1D"A�TE •!�� PERMIT No <br /> EH1324(REV 10A$1 � 1 Pc'/. r,(� )-A l (fO�-� <br /> EN 14 Ta !JJ �_� __2f <br />