. m.. - r •rt icyrRrt aStmT
<br /> APPLICATION FOR PERMIT
<br /> Xz
<br /> 1. BAN JOAQUIN COW/Tr PUBLIC HEALTH SERVICES
<br /> 1t ENVIRONMENTAL HEALTH DIVISION
<br /> {:
<br /> .f- 1801 S. HA2ELTON AVE. , PEONS (209)488-3420
<br /> P O 001 2009, STOCKTC", CA 95201
<br /> PHltl1IT S7CPIRR9 1. YEdR_FHgE DAT�y IBBU= -
<br /> (COmplete in Triplicate) -
<br /> Appil eaef ea Is M»br roa,to 6aA Jaaqufn Cama fer ! INrrtft to eanatrwet AM/,,r lnstal3 the vert M»In aeeerfoM. Th1a
<br /> opplicltim 3a rQ( in ee1'IAa v1th BAe Joaquin Count) Orolnanea go. 549 AM 1%2 ani t1M I ov aaE Maulatlona of(an
<br /> if lepuinlla 1/AVNa1{a fen(
<br /> AnArM J/t� ,/J/ /�+ CHY t.o�i e/l/aFe/4ere+p
<br /> .. � Ovww•r N �`/E!�'�-� ./"� ./A�/O��d/M//���//
<br /> 76}
<br /> S Cenlr(<I Mdl![4!�'✓!n ' / LI<rnie No �ZJ t Z� �S�
<br /> TYPE OF WE ' PUMP: .r: NEW WELL ❑ WELL REPLACEMENT ❑. DESTRUCTION O UFP of Harr/w II
<br /> jf
<br /> PUMP INSTALLATION O SYSTEM REPAIR Ll OTHER D Mmftorfna Wil O
<br /> f
<br /> PteT6SCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.LINE f
<br /> . FOUNDATION AGRICULTURE WELL — OTHEP WELL MS/SUMPS r
<br /> Yom} IH.EtiDFL USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS
<br /> )( In 4rtruw ❑Open Bottom ❑M"ets, 04.M Wes E.cawatom 04,-(woo Cookv
<br /> 6a•nwlc,P.rvsr! ❑Ora•N Pact ❑Traey Type oI Caanp SPPtlaeatlerr
<br /> tl OrNw h Dots OMEN o1 a,"Seal Type o( C
<br /> Apaoa.Depth 1 1 E!ltwn Surface Sees Seel Im1Wh by
<br /> ,p,,-, Rapa.'Wart 0 0 Ttpa of" ------ H P. SN:-Wora Oa
<br /> OtsmecWln D:n+rew flaalfua Material E SNytN
<br /> t L7
<br /> wtA P
<br /> 4 Owl, .®.. Pillai Mtterlai i Depth
<br /> r 'sfer" .`TYPEGF SEP IK:\MURK: NEW 4N5TALLATIO61 I� I A A,PI OOITIO DESTRUCTION I 1 IND aaac ryttwu Parr.urtM it M�bat twrws �,".�,�y raaaw wnr,m 280(esti .,
<br /> a /tybd r YNt asdM v.P wn: Rb10[r�ae�'Can w Orem
<br /> Marta, ��q®f
<br /> /
<br /> iy Ch,r w d"IF b A Eno1h d i NMI:.—° �I -�a ., West,
<br /> r1�Mn !-iL
<br /> pci{�./fi L tET le"A.NM: '-O i to/oma CWaNtY _.. No Cp"Plol^Nws
<br /> yr r MaHa0 of O(Hp[+r ¢�
<br /> N
<br /> OYbrxx t. rowaa: WN Faldetian_.—__ Progrly lila aF.
<br /> 1 � /' i EAr`iINC UNC Ne It LMq,,1 u, �1�1ry1 T,?I tonth/dH /271
<br /> t�
<br /> h i 2( it FILTER HED ❑ 111ew,e!aG rlawuaE W4.a�}x F&Xxwion__.��_ Propeft Lina
<br /> sw"A PITS X 1 »broSin pp-Poo W.'
<br /> s�^ t 3 7+�� n >yT r�fl1MP6 _ CI OMund IJ rwrM: Well _ Fae,,._/�_ nppMY,ln.
<br /> ;dPONDS N08...-,`,p« ., . I _ _ .'i, ott�y
<br /> n7 5�, mat I,haaby PartRY IN[t I Royce prapMW thl(aopaaaDen aM coax iM vro,t wi W 4aM In accayanc[ wAh.$M1 JWd1M1 CarnRy orAnlnOM.;01FIa aPMr aM .xJ�
<br /> pp eafl�s 1 '�` ,ruwl Ma nOo4stIo,N of W I a,llopufo Cobety
<br /> r ;C c ,y i i Honk ownw a EKar1(aa a9.W,flprwtura d trace eN fo(awn8:'I co Wy the m 1M par(ormsr,cs .ha resat far which/Ne PwR+t is' rot ,
<br /> e wrdM+rW P01011 k,a,h mares,to W batonw wbWt a,.wtmsn't mnsetr If n Is—of CW x.'Cawacta/n NeeV w YWwRp I
<br /> iM Iotavi,5:'7 CaNKY tlult h tM pwfanuncs of Mr woh Ia.y.Airh tM plrMe b W ud, :r.'w,gaay Pwaona N.t[rKe b wtmarl'a p1r11pe1(II'
<br /> hoes of fANorrW" .�(/r ,..
<br /> 4,PIk:w CAI fw 411 t/w�na.ComPk»&0-1 p on twrr r .
<br /> Dm! 4°
<br /> FOR DEPARTMENT 691 ONLY
<br /> Otto
<br /> trsl ' l4�I rAPp(Ptlen Aneap(ao rr-- "T7�� — q
<br /> x n X,"
<br /> O,oln IrtaPantlpn M. -.TN... Y_JS1lEL: FL+aI NwKtwn by Ti- ✓ f
<br /> DM
<br /> t 1 e (�`"� 1tea4ww Cal+w,u
<br /> y,a: si1' s r, °Opllemt as all oo►/aa to, H+an Strquln County Pubue.Maal4b,
<br /> rt rai, JI,u , -� st`y c , Baryteee, Ieyftrt A... 0 3l x PlnM4MCKi 1,
<br /> SEAL I. Lslltm Ae.. P'0)oft 2009. BLoettw, to 952L7
<br /> e�}�] NK AW%1ryT W6 ANOVNT RHNiITf[D A h RHC[N(D II,- P+�ATE KAMt NC.
<br /> -'-
<br /> r�
<br /> a/ r
<br /> � y
<br /> t
<br />
|