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VJ/LU/V4 lv.L'! Y.a1V .alb .aa.&v a.1 vva�a aa�a.aauaa. r�--- <br /> SAN JOAQUIN CROAT? PUKJC HEALTH S88VIC83 <br /> ENVT----- SB',tAL HEALTH DIVISION <br /> 1601 E. AVE. , PHON$ (209)468-3420 <br /> }� P 0 H43X 2009, STOC= W r CA 95201 <br /> VV ,, <br /> PB81'IT BELIBSs 1 YHAB <br /> (Complete in Triplicate) <br /> ApPlicatUn is hereby mWe.to Baan Josgeia Corn W rasp a peralt to westrnet wwo r Install the work 11% in described. Thi. <br /> apIPUcaniaa Is rids la e00P GMM with Sm Joaquin Const? Ordinance No. 549 and 1862 and the Rules and Aeg"Atic" of San <br /> Josgaia County Public Health aerviaee. <br /> Job Address / /fGmoi-- C, e C.W:5X= Cx% cot SLWAcrtese cZxPez"5 <br /> Owrnrs Name�AG/GiC c- Adamm zGAK ,�q�•P.Q.- Pt,ene�sicJBz'�- <br /> Caatracter8!L ��+� <br /> SAE, w-. ,aWdp <br /> yasCTlt�AF ucene Mo.�Ard%S9 >°hm ao T s7�t-Vag <br /> _ <br /> TYPE OF WELIJFUMP NOV WELL 13 WELL REPLACEMENT ❑ DESTRUCTION d2,0mt or service Vali 0 <br /> PUMP INSTAI.LATI4001 ❑ SYSTEM REPAIR C OTHER ❑ . 1lmltortaas tle]l C3 <br /> DISTANCE TO NEMEST: SEPTIC TANK SEWER UkES 7 DISPOSAL FLO._ PROP. LINE dc 1CO, <br /> FrXRyDATION c-:92: AGRICW.TURE WELLZh=�OTNO WELL � W31SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS <br /> 0 Mo wtan ❑09mo samon O Mataacs Dia.of Wan ew4w wan !Z OWL at WeE Casirs V tae 2" <br /> n Do ramwPriwts 0 Gmwl peek a Trap Typo of Clam F14:1- SPecdieukKa �5 <br /> III Public In o"w 1 I OeOe Doom a1 Gnaw Seal � Tkw of Groan � <br /> I I h gsNon .�A0was.OepokI Enwrn Sudace 5"Issmbed by ALwiusn.lG� /rs"ci�/ <br /> Reye•Work Oome Q T"w at Pump N 'd N P. a(F� sum wo*Oans 1A <br /> Wd oeswuc*m 101"was Oimww�4C JA 2" go""R Material a aer" AiM <br /> Depm IRM IS& Lie Pular Material i Depth N31 R <br /> TYPE OF SEPTIC WORK: NeW WSTALLATION I I REPAIRJADDITM i I DESTRUCTION I 1 IN*mom aVaaan perrrwted d public sewer w � <br /> aws+labM wiOlin 200 feet.► <br /> inuaaadon will mere: Reddnree s CommsesW_... Oaw <br /> Number of limina w ruin iws tw at bedrooms Gq-wfL1r-- <br /> C�Q Chsesoar of a"to.depMr at s tact: W~Ish"*, <br /> SEPTIC TANK 0 Ttrps&ft capocih, No.owww"Iwas <br /> PM TREAT&UM PLT.0 Mlew"of Ding" <br /> Ohlsaes foe mwwate - van . - Fotlrlastinw Property Lire <br /> LEACItlNG LINE D No.A' d Iliac r TOM Wroghisaw <br /> FILTFA BED ❑ 01iIaa18 to moment Wall Propww Life <br /> SEEPAGE PITS I 1 Dep h Sias Number <br /> •- - — —.ow.... .. .�.�.. :taLr1laellbr► ....+.fiY ...w <br /> DISPOSAL PONOS 0 <br /> 1 Maty calm y Mw a hero pn1 (/Iia aPpb=Oft wad Owl Ow work we be damp n+oco(tl&M v"M Sae Jonquin empMyardnenees,save heel,an <br /> rules am onsl bme of the SSR iso4wn emem <br /> Your Owner or beau d awwe'a alptae.ros MMVIM 08 t+seEswrrls: "I cmr1My thm in fM OWlarmauca of the work for whish this PdnM is WIMMI.t shell nes <br /> =""V MW panni M 81810 rmenv as Be become eu#m to w0Nwasw'2 UMM§aseisn bwrs d CWkwnis.•'Cargq camps <br /> k1oft se sIr 1comho �'1�"Win tM +kln0 or sub•eemrecaq agetatun <br /> tion Ills d Cdisr1118" COd IIe 111�Ik for adlrt0 Ihn Parma n I dkf8 twrlploy pnaarw sumac;;=w nkmenY con*wm <br /> The appfkwel acne ad for all wt WMW bwasomme,Compm a draw wo an Awns aidp. <br /> swwd x rdhc �� a -* DowCoe <br /> MF'. FOR DBPA/ MWNTT USE OILY G <br /> App icackm Aeeapted by M-- on* y�I !s' ,fie G•v.P. <br /> PR or Groat IrMpseeioR by am_ F;IsI aa'vw++art 4w t� o,r � � � 1 <br /> A*ftw.l comme s s: C t u,) <br /> As�la:.et - aettwm <br /> an am&" toe Baa Jammu Colatt Pabll¢ "a so <br /> smaxta <br /> ranaysernew <br /> 1b03 L MMLt- a,Are.: P 0 Not 2009. Staehtoa, CA 9520.1 <br /> fEE <br /> Iwo AMIOYNT 011E AailO{1NT REMITTED CSN 0Y DATE PI <br /> D _M—IT NO. <br /> :N aa .,.. da �! S. DO65E <br />