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itd r� yi� „twTyr°�e�" :A • e r�1?Pi x &'A' � � �e.��Sr„ <br /> r i �'".I � a �� 06f <br /> 41 APPLICATION <br /> SAN JOAQUIN COtWrY PUBLIC HEALTB .;ERVICES <br /> ENVIHOIRILSRTAL HEALTH DIVISION <br /> (. , 445 .N SAN JOAQUIN,- PHONE,(209)468 3450 <br /> ..h. P O BOZ 5009, STOCLTON, CA' 95201 ,'s.. <br /> EX 2e:.- <br /> �r, I' .P.ldl r'r >roIR£9 Y YH!ut PROP DATE I adBD <br /> i` - (complete in Tripl:.cate) �r <br /> AFF11Cetlpn If Mret7 =de to Su Joepuln CCVnt POT a <br /> y perch to coi No. " aeoI abbef lifted, <br /> IAIW- <br /> T yry:alla Cak <br /> it free En ete�3laose HN Sat JrwRu!n Cwnty OtN irNnca No. 719 ono 1Pb2 eM f�NSW"' <br /> aC¢la Crony TIe11C tlKltA Mre1CY.. �"aN <br /> _ � CARc .fA .-- — — c tw3P dt <br /> �. LotBAaal <br /> Addrue <br /> .f <br /> Nc 'P1S31t�.�)MenE�FE/'��tr- e£w +Irk `Y <br /> �f hEI PUMP NEW WELL Z WELL REPLACEMENT 1 CESTRUCTMN O Ofilti <br /> Ibtl ! yE <br /> PUMP INSTALLATION SY,,TEM AEPAR ❑ vvS..O�� IIFR'�� = W <br /> >•`•C O NEAraS'T SEPTIC TANK SEWER LINES bISPO A LD"'"" <br /> - FOUNDATION _ AGRICV LTURE WELL_.__.. OTNER WELL <br /> IENDED.USEV TYPE OF WELL PAORLEM`AREA CONSTRUCTION SFECIFICATIONV; •.J � 'L'", *+I �1.� t p,,:� <br /> art 41 O Open Bottom ❑Manteca Dia.Of.Wall E.avetan - <br /> o'neetK/Pr'rvary 1 O'evel Pack - Ll Tracy Type of rssinq 1peeY .66"1 <br /> i c due i 1 0 her I' D.'Ia Goforth of Of., Sell .�_ z +TpA N a] ..o-YXe,� r.,, (• <br /> gle•ron ;A".. Doom Eulvn sudece Seel InnaMd <br /> Paper,Wok Dona 2 Type of R mp N.P. _ 5mta Wool oOyl>� <br /> .nra11 Datkuctbn <br /> Were Diw'rwt. __. _ Nea:Io, PletaYla3 a Depth -A^Asf§si 2e xaat IF 41� <br /> Depth r1l1ar Matei•iai A Depth a4YYI` q Iyi i !,il <br /> -:'r'E OE SEPTIC WORK: .NEW INSTALLATION REPAIRfiA L-0ITION GESTRUC TION I IN.Ypkjgp�M <br /> I) -.Pe alstgn.1 u'w Residence <br /> NumOR of roup uM a ..j._ m.nd•oom.._L.3— <br /> C'fwacter of W,to a papth or A Rile: <br /> &for I"TANK Ll y'".lWoHe4, fy ,�r(�•1a 1 <br /> r' <br /> e <br /> y, 1YryI PKO 'REATMEidT KT AYtl6aee�A1� r <br /> ` Olvento oesoNt Wa'_ F"Mstion, _—. P arty <br /> a Lirw! <br /> -EA Nr L Nt ��( No. A Lerplll of fn.. ��p.1^F f T rote)a I/ <br /> rcL F RED Diatenea to rvkal.e Well Foon� dation�_ P . <br /> SEEPAGE PTS Depth _ _ Site___.. <br /> SUMPS Distena to neereat: Wo FourMelion___ r nefEY l`1fiA <br /> a F C�SPOSA3 PONDS n <br /> I MraoY Canify IMI I neve prepared Inn apprcuwr .1d hat;M-.wxk Ill W done In acco W a w San JoeeluN Caurytn <br /> faro and raquW'rone of the Sen Joeouin CPunty <br /> Nome owner Or Ikeneed'penl'a sil)neture arhfree the f I'C ving:"I Certify that In the arec rMnce I wo,1t Iq wNER IEIIA <br /> 'w-,&y any pereon M wh Tonne,as to tNCprne wOlec to workmen a-ompirul,on Ewe i l Cefifo,ril :or trKl0 61171�1�'elY'{I14 <br /> unlf"the foeowin9 "I anify that T,the performar9.e of the work for v filch tris pelrvt a lead,I et';; ^r�pby prNWM w NG'1�011'I14R^� g; <br /> •fpr Dva of CWlorr.e„ 1 <br /> +; 'M appucent most CoA Ior YI/eryurr MWsctiona md,.. <br /> ng dranp on 14,14,.1%,vet .10t *'� •'i <br /> T.111: <br /> •FOR DEPAATMENT USE ONLY 'L <br /> Date_ ZZ <br /> .yn 3 7 P•.. w "'a.• I`+aoeCtrin v _.__ Da!u �_ 'Inst Inapecuon by <br /> JPf t.111N <br /> Mro <br /> py <br /> Iee.ua all .uDlee to: San Joaplin CCnnty Poh1lo.Health Servi•-e• <br /> Envli<neental Health Patelt/SaYrricee - <br /> 7r 445 N San Joe ,,", P 0 Rol, 2009': Stan, CA 91201 r` ' <br /> 1 fi NFO AMOUNT DUE WOUNT PEM"EO AY 17 RECEIVED oY 1 DATE^' rERMrt ND <br /> r� <br /> k tY'w`%cA1...Swts Std. .ro ,».:wnaV 11+ nkS aaq+.gY' +p xwrfi v. ;•'- v S. 1 <br /> P h � 4 1 o- 6' Y'• ��t L l2 Ii. ..1 Y Y) j r.'yf� l � <br /> � i,4 d '� <br /> I1'� + 4r1S,. 11 { p ',l 1 '• <br />