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TI.N-1�J-1y' 1 1S:�J'i FPal AEGIS ENVIP,OMENTAL TO 122094640138 P.@2 <br /> APPLICATION FOR PERX17 UVI <br /> SAN JOAQUIN COi3M PUBLIC RFALTH SERVICES <br /> BN7IRO TILBNTAL ESALTS.Division <br /> R 0 Ba 2009, &r XTaN, 'cA 95201. <br /> (209) 468-3447 <br /> (Complete is Triplicate) <br /> Application is bOrtbj' aedO to $sa Jcaggist Couat7 for s P+rst: to caastraet %3d/Or-install the nark bertiu described. This <br /> tppllcsLiaa i! itsdt in compl.iSnce Vit�h $an JOaquitt Cauatr psdiaMee 8q. 549 84d.1862 bad Ib* Rue*s ana Aegulatioae <br /> 400,01aa Co=ty Publte ]Rath agrvice.. Of Baa <br /> Job Addrtss CAY ICC' Lot Site/Aereage <br /> Re <br /> � q C <br /> Ownw's Nww,&g t� ,// 4.4+ee .� alb,Address/ F S1. f21r'Ayl� 9 p ne o - <br /> Cantrattari- '/ Address G 33L ,' i renN �� / Phone <br /> TYPE OF WELL/PUMA: NIWWELL ❑ WELL REPLACEMENT Q DESTRUCTION Qo! Servicer 21.1 <br /> PUMP rNSTALLATION Q SYSTEM REPAIR C] OTHER C15, <br /> Ifonitoring Went <br /> DISTANCE TO NEAREST: SEPTIC TANKSV VEA LINES 3l:`--1V.t' DISPOSAL FLD. L <br /> FCUNOATION Z:.0 �e r AGRICULTURE WsLLv►�r •�•oTNf:f: wEIL PITS/SUMA U, �n <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> CI Induraial ❑ Open Son txn 36 Manttca.— 04. of Wei gxcsystio f, Ota. of Well Ca ' 2 4 r, <br /> gOottttstielPrivate Gravel Pack C3 TYPO of Casinq_ &JC SpscA7citiot►s <br /> Q Public n Other C] 0*118 Ceoth of Gran Seat 'M Typo of Gr v <br /> C Irrigation _,,,..ApMax. Depth ❑ Eastarrs Surfice Scall rnitallad by c <br /> 11Oorir Wort Don* 0 Type of Ptlntp ---.,.,._.� H.P....�.�`-- State Wq,* Dont <br /> well Destruction Q WNf Diam*Nar — SO&LU4 xateriai i Dtpth <br /> 0"Ih Pillar ALtortal 4;repo <br /> TYPE OF SEPTIC WQRtt: NEW'INSTALLATION.LI REPAIR/ADDITION ESTRUGTION G (No Seotic.systsm p*rrnitfed if pubk Sower is <br /> Instalytion wEt rout: Rei+dtetoa C0Mff 9Af_ Qthrr SAN J0AQUWi 'Mir$ 'k HEALTH SUM <br /> Nuntbitt of q utt;te; NVmber of bedroo," <br /> Cha►sctK of roil. a dptft of 3 feat: ' '" " —_-. 7--P <br /> SEf TIC•'TANK. O Type/Mfq tG94city-.: ,,�.�� Ffo. Cort�arir:tsrt;j �^ <br /> PK(L TAF,ATMENT PLT. 0 j Method of bis;7oial <br /> 0115Unee to nearest. Wen F9un'da11,06t _ Pr" Iona <br /> LEACHING LINE ❑ No. b Length of on" Total IanQth/Slit <br /> FILTER $90 0 Orstance to nw m; WON Foundation s Property Line <br /> SEEPAGE PITS 1 1 Otpth _ give Nurnt�*r <br /> SUMPS L:1 Oistanea to nstrtit: WIN Foundation ` Property Line _ <br /> DISPOSAL PONDS © ••- <br /> 1 hereby cart;fy that I haw tx*pared this applicatiOn end that the work will bs done in sccortlanu v�itft ssrr JtlaQuiA county otdir artcss. state laws, and <br /> rulai And r"wiitiorm of the San Jtnquin Comfar <br /> HCAtr owner Or I;cansed awt's signature certifies the following: "1 cartify that In the performance of the wont for which this gartttil h isstsad, ;ihall not <br /> employ any person in such manner is to Wcome sub*t to workmen's compensation laws of C4 iforra;s,"Contactors hiring or sut>`sontrttet;nq signature <br /> tionirk of f� NI certify 04t in the pafof,mance of tht wafk fol which this POM*Is;slued,I Shall Ornploy,persons subject/to wtxs<msn's eorrsptnia- <br /> The appfraett call fof 00 r quimd intp!etlons. Carttpiate dawi an it NI+/1 r+l��.'y/j � *�• <br /> ^q revtrst sidO: <br /> S�QMd Tale• r,i` �A• i tar• Dan: ts9 <br /> rFOA DEPAOITMLW USE'ONLY <br /> AAolicatron+ +at' GIJ cF a / 1 /0 Area <br /> m <br /> Ph or Grout Ir+ip*etrort f>YEW <br /> Date di//nut w <br /> ' ---�- <br /> F'mal n by -�7�_j� �4r`� /part !� `�1� <br /> Aditonsf Con+n+ar+ts: <br /> ilyplicaatt Rsturst Ell copiaa to: SAg j0AggI1r V <br /> COVN7TPUBLIC 81i8VIC33 <br /> ENVIRC VENTAL USAI.TH RIVISIOif paXIT/BERVICBS <br /> 445 X SAN JCAqul,4, p.0 SM 2000, WrocXTON, CA 05201 <br /> IWO AMOUNT DUE AMOUNT REAaITTEQ CASH AICSI ED 4Y DATE pERlbt1T'kO, <br /> I174 IIINI+� dry —fir ,r76 1. <br />