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_-1C3o65657 TAW . PROTECT SAC 994 P02 RPR 27 '92 15: 16 <br /> App),ICATION YUx ru"11 �wh�Ati <br /> 8AN ,IOAQUIN COUNTY PUBLIC AAALTS SSAVICBB <br /> y,NVIAONYSNTAL HE&LTS DIVISION <br /> 16QX pro BOX 3009,VSTQCEArtgg20 <br /> TON, CA 95201 <br /> Cotnpletq iu Tripllcltta) <br /> Ust <br /> Appllcatloa ie neroby 10411 OEg i9epto Cotitlty Lor a ligmit <br /> ( to oo(etrucc egdlor iWE611 work bortP d�gd. a <br /> tppoTan <br /> applicii to made to ocdq?114 <br /> 4oe viib Ism Joequlo County ordiredc9 Eo. S49 *pit 1862 9-o sibs A lte 116`t <br /> Joaquin CQ,i Public 99a111 1GTV494 <br /> City <br /> J3.o�F tiiat/Acrt►6o _!-sig, r <br /> Job Adar•a• <br /> S Phone "it GS— 32 <br /> d.�a i'Y • i_�y __ AddreN C,� CIG) <br /> Owmr'e Nam• �----r .. E S <br /> 11 ��L[90 _ s fJ �_ _i-Ic1nsa no.�'f 1'110"Q <br /> Conl`act°` W[LL R[PLACEM NT Cl p�STRuc7iPN A WF No trvtat ell ❑ <br /> TYPE OP WELL/ UMP. NEW WELL O DTHF,R ,1146 rto� vt11 C7 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Cl <br /> SANER LINES DISPOSAL PLO. PROP. LINT <br /> DISTANCE TO NEAREST: SEPTIC TANK ..�Q� PITS�SUMP9 — ►" "� <br /> ,� ,� I AGRICULTURE WELL OTHER WELL <br /> fOUNDATION Jae -- <br /> IN7END1.E0 USE TYR!Of WELL PROBLEM AREA CONSTRUCTION <br /> ` � p'NQj CEO;+? nIfICATtDA of WEE COON <br /> n Induarial ClDRom p file" <br /> � - <br /> SPloiffcitlgrui� <br /> L7 T Type of Cal <br /> cy lnp_ <br /> C.I DomaticlPrHate Q GtEY/l 11St TY <br /> QePth vl Grout Sail ---.----�" Typovl 4roW�------' <br /> Il Other n Dula <br /> I'1 Public <br /> Suiri 6941 Installed by `-f- <br /> h,igauon —Approx. Depth 1 I Ellam <br /> M.P. Stiff? qfe Pont <br /> i✓ <br /> E— 1t•/ (,Q..KA.�~ <br /> Repair wo,a Dona L3 TYPO of Pump 6ealtpII IMtvi ial 1 D90h <br /> Will Destruction CI WON Owpoaf Pil19r notartel 1 D9I rj <br /> Dopth ----•— P yIII <br /> Tv►E OF SEPTIC WORK: NEW 1NSTALt.ATION I I REPAIR/ADDITION I 1 DESTRUCTION i #V#at)9 at In 2 Mrp;it1od 11 publ,c wwar a <br /> Inataeation will "No: 1190119(1 .— Comfrtefo191— Dtbar I M 200 10911.1 <br /> Numoar of 1i VAI Number of 044,001 Witter able dopth <br /> Cho,+ctM of 9oa to o depth of 3 IAC Captcily No. CgmpenrrlMto <br /> SEPTIC TANK ❑ Type/Mfg Method of Dllposil <br /> PKG. TREATMENT PLT.Ll Foundation PrOP'lly L"Pktonc9 Iv Marga Wel <br /> 7o1e1 angth/Ek/ �. <br /> LEACHING LINE 17 NO. 1 Length of INea Foundation Property Line 11Q Diila(ce io Mara9i� W+01 <br /> SEEMGf PITII I I Depth Efi1 Numbw <br /> SUMPS LI Platano to notaries! <br /> DISPOSAL <br /> Property tIM <br /> DISPOSAL PONDS la <br /> I hereby canify that 1 have Preptrp this 41pplk9tlan and thel rhe w9rk will 09 done in +ccerda^ce with Llan ao1941n ggVnty ofdWnll. state Iowa. and <br /> rules and regult ions of the Son Jvoquin CoWlty <br /> Noma owner or NcanMd ogent'0 09069-19 aniOW the following: "1 uni1Y that In the perlormanc9 of the wore for tvhlbit ng permit K isiw4. I wona not <br /> •mpwr+m p9-On in ouch mann#(as to becofre auDloct to workman'0 comleneitipn law$of CONlwnla"C4Maa{v(s biting or wPconuactkp siooawn <br /> e•nih•s the IoNowing; "I lrtih/this in tha pwfvrmanet of the work for which this portrait Ia iqu9d, 1 ahlo emplvY perMM Ivbleit Ig wMkmen'a eomWnu- <br /> ,ton Laws of Collforniti /. <br /> The apptican I ON lot 14 Ir d ln#Kclions. Cbmploa drawing(o�n Fevii iWa• /''� <br /> Tab; °Y l.7Fo(41 r Dote: —L.----- <br /> signad <br /> FODEPARTMENT USE ONLY t/ p <br /> �-v <br /> !(_ z Z Arg <br /> AppkatIOA Accepted by <br /> Ph or Gfout lnep"00" by <br /> T,net Pea Z�f c)Z FIMI Inat»ctioa by Date <br /> additional Comrreote: . <br /> Appllaane - R•aurti all oopila to: 61+1 ToagPid County Public Health <br /> ib011t�aA1a�91t0000A/UlP 0 Hots 2009 tl E6to holm, CA 95201 ��.ov <br /> fE! AMOUNT OUE AMOUNY REMITTED CA11 1N ECEIj,,, ,,y OATSEn <br /> WFO r7 <br /> I" I3 <br /> t,•u .O� .T/ J <br /> EH I,]♦ <br />