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<br /> APPLICATIO[f
<br /> *, f , AN JOAQUIN COMM PUBLIC HEALTH S$RVIC83
<br /> d IVISIOi+T.
<br /> � ENVIEONYBriTAI, HEALTH D 09)465
<br /> � 445 N SAN JOAQUIN r PHONE (209)468
<br /> P O HOZ x009, BTOC[TOLR CA�95501' + �
<br /> �t •w •; PSBIf I T BXP I EES 1 YEAR FE(EI
<br /> +W (Com Tete,-in Triplicate)_
<br /> Ayyllcation is Manby aaM to Ban'.Joaquin County for a perait to construct a'W' or lestall mwart be" d sirlb
<br /> r M , application is mile in cosoliance vith Bao Joaquin County Ordinance No 549an
<br /> naed 1862 R IiW' dab
<br /> Jopulit Cour Public Heraltb services. /� w< �` ar •
<br /> `Job Address or 6 I f 1 S(\k j-e S City, � G o 81tf/Aa
<br /> r E{ Owrrer'�Name l�r n f`y rb/- -=� Address S•.is�=�
<br /> r'�Cbnlctor ` Lk nee
<br /> IsAder No
<br /> est a
<br /> E F WELL/PUMP / NEt 0 WELL,J] WELL REPLACEMENT1 Ll '�� DEST11 y tiQ7
<br /> Fy k k PUMP INSTALLATION'[] `' a, SYSTEM IfPPAIR n x y OTHt1Gt x
<br /> DISTANCE TO NEAREST: SEPTIC TANK , SEWER LINES 01$0OSAL FCI�
<br /> ty ,!`fi',•. . ..__.... FOUNDATION . ., AGR7CULTUf{E�WELL ' 'OTHER•WElfs'� " 'M��
<br /> 3
<br /> •. �. T?1}'i AW?�i 14 tt re s .-WLL ` PROBLMARAREA�.CONSTRU,CION3INTEN0E0 USE TYPE Of .SECICAT10NS + of In. ` •-
<br /> y r+, Ll induatnal > 13Oyer►Bottom "�ma loc � 'Dla of Wel Eaewstan
<br /> D6 $IiC/Prfvat* CT tinvN Pak ❑Trar P Type of Cai&g
<br /> T
<br /> Public t 1 OIMr t 1�0eis O'Pth of Gtibut SeN �¢ "dart
<br /> � ! *= 1 1 Uti�Ilon ..l _ApproR Depth i f Eastern p Surface Seel Intaled W!
<br /> w �� Rp VVnrk Don. O True of Pumi+°_, ' t H p S�atd W«,<'oonr t�
<br /> •
<br /> t_ J: Ati.11aterW a'
<br /> Oestniextbn O WeM Disnwter �r w
<br /> IDWh i:' '' ,7�].ler..11atallal♦k 3 x, .{`s{ '
<br /> t
<br /> r + r "TYPE'OfS IC00RK.', EW INSTALLATION REPAIR/ADDITION{I OESTR CTION 1 1 tNo asptireylaem
<br /> qqyy - yy _ " '. �' 2 evarlable,°itritlYh bdil�jY.� b ,ra.�
<br /> ;f n r IfNt114tio11 Wl1' R -Comm inial Other y U n u s
<br /> �Nufflm of ley t9 vnft _ Number of bedrooms
<br /> r ;ICAMiotia M sell a•dapt6 of 1 foot: "` ba GLs 1 eli
<br /> a w r tea•+, E PTIC TANK`-' me'/Mfg
<br /> �PKG TIIEATMENT PLT q , f
<br /> a h} f Distance to�noor♦st. W400 �_Foundation PrcgteAy u
<br /> ti lE♦>,CMtNG LINE P<No 8 Length of Ones 3 xToial lertpth/
<br /> a�XfN TEf+'BED O Distance to nesrett Wali a in I;rC x
<br /> +.�yt�� �,,.;y� ,r � ; i Sy: i.zz .�, a �:`Y' 'i Iv .ir r✓/X?�4 � :`�',
<br /> �f1*AGE PITS
<br /> Distance to now WOE lice':!j D Z
<br /> �,;�•a +^ >DISPOiAI PONOSa"i �' } - „r, is?{�� � ,�' •"'� � �i-
<br /> r hereby%;0T0v that l'Sove prepared this applies on and that the work will be Wxw in dee o Sen of "'CotMt "
<br /> rulaf NW rpulatioM of the'SM JcWuin`Couri
<br /> r ` k uowner or 11censidegent'a iignture artif' the foNowing. .I Certify that' e+ }the wdrh
<br /> Nnn
<br /> 3
<br /> "employ,
<br /> any parson in such menrw as is eubiect to workintt's eompota at taws Calif 6omflel is Nrih�f�r `
<br /> ceRNla Ua folowinp: '1 eeltilytMt in the peA of the work for which tl,)a t b slsM empbt+ptNltitla2 e
<br /> tion Inwe of Colifornim•`
<br /> The applicant mut cal for el mQuill0d Ift a.Complete dfawetg on nn
<br /> Signed . . . t.Tidsjele.Q _
<br /> F rs"
<br /> , , -,.d'r t ` +.5 Amy m, b
<br /> FORDEPA USE
<br /> �•A` tion Accepted by
<br /> Xt :. •
<br /> s
<br /> Y �t
<br /> or Grout Inspection "'. haat Inspection br WE °
<br /> r {" ddldonti Comnrnte:
<br /> tk�s"r Applicant - Be turn all copies to: San Joaquin CountrPublic tlealth Servloea t r' °�
<br /> Environmental Hoalth Perr��,'t/8ervioae
<br /> p�lA�z 445 N San Joaquin, P O Bdt 2009 8tkn, CA 95401 ig .'
<br /> >x
<br /> 7t d4 FEE AMOUNT tkJE AMOUNT REMITTED CASH r RECEIVED s OATEN,"r fiEI1M1Y$lt
<br /> {e INfO. _.
<br /> �' n, sok 3 � �•°��l P
<br /> fads lace r,�.r SN ,Lr Y © . , z
<br /> +� b0 3H, 0. 6 1 �5 `lam'
<br /> .s«teas
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<br /> �•* Iy.-4 � �'� WM¢a„r•rw+worn... � :{ :C• y +1
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<br /> d$ U f fi r a Y
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