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APPLICATION -� <br /> SAN gUIN COVM.PHBI+i -Clz HEALTH IC83 <br /> DiDZBfiTAL BBALTH.;DIVISION <br /> 445 N SAN JOA UIN, PHONkt 209)468-3420 <br /> P 0 BOX 2009, 3 , CA 98201 } <br /> P22'T t11XHttt>m4 rt <br /> , r am, AM= <br /> (Complete is Triplicate) <br /> REFEliLrea <br /> heseDlr andtt,to i $,1asPya 'for, ye s to eonatrwet aWor ssltsu the work heseia'as.grie.d. This <br /> atsbe is caitpWines vitb'tiro JoaquinCcitmty " ossce No. 549•sad lWe ariltSte'Mules and frs9atlatieos of tlso <br /> Public Mealtit ita!+trieb.. <br /> Job Address Li r e City bck iu►tot Sieh/Acreage' <br /> Ownses MMn. ..�l I►�► .t. a #.r1 i!'-x,. Addnne 9 <br /> .. 3�f �w�✓ dTPI+�Ju,'XJ3' rll�sr�!�te"�tE<'tt�/ �t641�dn ��7��t� <br /> Comrsow, Address Mo.G T r+SbtR,e pia <br /> TY P W "IPUMP: NEW WELL O WELL SIEPLAC046NT.1.1 DESTRUCTION O`Out or perriv 1012 <br /> PUMP INSTALLATION O SYSTEM;REPAIR CI OTHER JR.,JpM ys SOS 'tell p <br /> DISTANCE TO NEAREST: SEPTIC TANK T,, SEWER LINES J0tV. DISPOSAL FLO�� PROP.LINE <br /> fOdNQr4#16N ;,E,� AGRICULTURE WELLAtAE .. OTHER WELL 2aL PITS/SUMPS I.W <br /> INTENDED USE TYPEOF WEL{.. PROft AR1 A CONSTRUCT" SPECIMATIO" <br /> n Indust" O Open 8ottont O Manteca Dir. of well Ewaystion Dia.of WO Cssinp <br /> 1 1.Dernratielt to 0-Greta Psct O Tr4cq. .a _.TV1Wof C$Vft rw.yi • Spealications <br /> : 11 Ptdbik At o"WAIi l .�i'ONta 041M*!..Grout Ste . Type d tirout <br /> A 1-*A potion ' V Aopr*,. Oepth i I Esstern Surface S"InstaAsd by` idtilKe__� ' <br /> "epar"bllark Done 13 Type Of" Htlli <br /> r .. State WoAr Oorte <br /> Will:�ott O wo DNsftteter ial. ♦ n pta►Deed, !ta sal�& D"th <br /> K: NtcW tNSTALIA T T REPA1RrxD01T►ON t 1 "siff'"UFFM I t tiSs 9, °syeroeM Ir P dit sewrw is <br /> oval"within�0 tlf t.l <br /> ImtatMtion VA Sartre: NOWdenee._._ Conwwctal t3Msr <br /> WIMMOW OfJW tE 4Wft ._ Nttea W Of bsdtoonu <br /> OWSG br of sei to a depth;ot 3 feet:.,._..,+_„ Water lata wpm <br /> SEPTIC TAM O Type/M►9 C+as�v_ <br /> PM TREAT~P.T.O pispoeN <br /> Distance to IN~. VWW Fow+ds Wn Props"tine <br /> LGAO"W4 0.. No.i LMV*d 1104414L 14 TOW W"Uvsin <br /> a W <br /> FILTER "A O DW$$M iq f$W � W •.. Fpurtdstipt_._.,_� Property ,Ina <br /> sEtiilAt3E PITS 11 Depthy,. ,_.,,.� •' Number <br /> L7 Distance t0 1"W": Ann' PropNty Lute <br /> O <br /> -1'In�ler then`!tMyl peeperw•thiesOpKsatioa;and-that tM Irak wEl be done 7rt aawrtdenee+MNh Sen JoequN ownty erdirtertt�etete'lawex-and-` <br /> now and of tete Sae Jt0040 Codaty <br /> Hoait.Owrtlir Ot)'weed#pot's silo"ceNd"ue 1tw.loNowinp:"I-ow*rhasin theme at*&*w%3or wAidt SIM reanN is iNwd.l eheN#W <br /> saMA9!►arp peraoa M etteh rttertnSr ire rs beeonu sttbiiat M workntMt's ooatperati of Ceww* ,' ►et<to $lririnE ae VA-Mnrraaunp 80WHure <br /> SS oil 1 //wa*,.w�Wbq:"i cwWV met in the potoa At fee whidt of•ms wiethis w 4swed,a el#aftlol►pps0+4 e�to woAunaty oomow <br /> Mala d 1�~ <br /> The ~a* A ISgdnO Irtape.96 a. Cafr*aw drowN'i0 an reverse*M. <br /> swat <br /> • /�/� / <br /> y <br /> r � <br /> . AIITME#fT Yti!flNi.Y <br /> AppMoatMtt Aeeept.a by :. _ OOIe <br /> Pb or Groot filipes" 4WVW Msteeetlor►by Daft <br /> A&*1wd.Caaiaual <br /> Applicant - Return all copies to: San Joaquis County Publio,NmUth ttorvices <br /> ' sii'taresilirest"'Us1EL IPosaat/Urviaee <br /> 4411 It Sas Josgala. P 0,boar3009. Stns, CA OWL ✓� <br /> AEIOIJNT ME AMMMT ItEMITTEO Atf�IVEO W...,. •. GATE PEi�T"N0. <br /> Vag <br /> DINO .�. . <br />