APPLICATION FOR PERMIT
<br /> SAN JOAQUIN COUN'T'Y PUBLIC HEALTH SERVICES
<br /> =WVIRORXIMAL HEALTH DIVT3IGN
<br /> 1601 E. HAZELTON AVE., PHONE [209?468-3420
<br /> p 0 BOX 2009, STOCKTON, CA 95201
<br /> r pg�IT lizvlRE@ 1 YEAR FROM DATE IgvUTaT
<br /> (Complete SD Triplicate)
<br /> cat,00 1.>,_by ted.to S.o JO•a,to Co mty for a P-r t to contract Aod/or lo•tall tT_kand Se 6e.rrlDed. TN.
<br /> ApPli
<br /> .,PPL1C.ttoo:•_d, !O eo�lt.ece KtL 9.n Jdaulo Camey lhAirunta Ro. 5L9.b 1652 and tL.Rul^.,and R.auLtioe•Of B•n
<br /> J..q A.Carob PHS.u�e(,111-11th S.r.t�re/•�. �t
<br /> 4 -,o,Add.w__�C�L�L�l-A(� "" /7, (�Cry J_tX��-�✓lot 9:ar/Ac rew6�_�TLL�L-=
<br /> y O-W.Nun.
<br /> ey
<br /> ConuaclN
<br /> AOdrett_ s Crntr No.
<br /> ' i T\PE 7F WELL/PI;MP: NE.YWELL O WEiI REPLA MENT O DSTRUCTION Ci orc ofM6.rrte.arV.11
<br /> -0
<br /> p _ OTHER O IIC300
<br /> 0( 31
<br /> PUMP INSTALL;nON C SYSTEM REPAIR❑
<br /> SEWER LINES DISPOSAL ELO MOP.LINE
<br /> s( q^TANCE 1 O NV'tEST:SEPaC TANK "/SUMPS
<br /> y iOUNDATfOH AZRICULTUPE WEII OTHER WELL_�__
<br /> INTEVDEO USZ TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION�-- �a
<br /> of 00.0 C..F+p
<br /> �l C,w.s.�al O OD•r Bo"o- G r.1.nl•c. Dr.of Wr.E.uvalon I
<br /> It(� (l panclPMW O G+wPk O T,. Tv �I Cr+.�9
<br /> TV"of Groot
<br /> 1'I Puh[K n ql+.- Il Nit. p.vfh d G-1 S..,
<br /> s _Avvoi. ..vIT -t 1 En'•rt. S.11-S.W 1W.W W
<br /> H 1 1 4..p..�m D _ S-W-k
<br /> R.O.ar Y/aF r-, U T jw of Pump
<br /> BeAlen[Ila•.nr1•l a P•p th_� I
<br /> WM Dec rvctb� O WM Dynv..r 7113er Maurial.Der"
<br /> P - - - [SIA 2 d�I podsrt:
<br /> TYPE OF SF✓T',W)RF: Nt\Y IH<TALLATIOM I REPAIR/A DOITiON' OE ST RUCTION'1 I.V h.2w 1W.1• is N �{['
<br /> FF - krts bM wi rw' Pu�Oanc•y�„CanerwaM ry _
<br /> J N— d p..,rxm. -
<br /> "AR[IE.r W~tad•dvlh
<br /> I): Clrac,•1 r1.OF C•Jopol of J I..0�_ Ne..Con4p•vorrn f �t�
<br /> O r.-»)M1p --C� ry - E
<br /> ETnIC TAMC M.thod d ONpwal
<br /> S
<br /> PKG.ThEATMENT PLT-0 \may r 4
<br /> ,.,:/ �'� - 0l+r• .
<br /> m n.•rW: WeE Foud.don___Prop•nT lLr
<br /> 3�? LEA.CH9I(i tYiE Ct No.a LiIWU'of•ros tL K Fars - !-ov�t�w Lw= -
<br /> '�> } F1l.T`.JI BEC- O CrsxarKs b rw l.at .-R+c-=-
<br /> S:EPAGF PETShoprry LYr
<br /> _ -
<br /> W,Y Fa¢.douon •�.
<br /> 1 is Sl1MPS LI D—to rw ':
<br /> CtSP�,SAi PON-IS
<br /> .G di.+POArA" .r.d INf M vrot wdI tr dar N,cco.erlc.w.h San.,c. .m c'AMIRr oro''eK lol.Miw:�d
<br /> 1 tr»or-10,trn I I—tt Pr•P•l i!
<br /> �..:. Honw am t,or,t.,"d�.qsw� c0io�quin -uf"dr 1naQI•a'Ir.�I c•rMy d..t m Iw�r.of CN1onrV_ Cor,_W.hftV w A.6M1Aowgl.IpR.D►•
<br /> - - ,r-I.1V -.r*wbY arrr vN't^N w.71 rtrrTr.r u b b—-1t0-b wpL+W�a torrpMr• S I.I••ood•1 NAl1.mP10'[Pw.ar aWR t io worYmwa.Ca„P.R.s .
<br /> cwGay tM laape�•¢7 aaMr dW h.d+t v��'^r't•01 Rr rrOtt for whin Ura P•n^ _
<br /> I
<br /> -
<br /> It •;on In s (CKlemi..^ CP,,,P d—.,q v:..r.ra..ad..
<br /> iTr^W&oe R•a t W for
<br /> 49
<br /> ?rd �jgI ten!
<br /> �4_ Di IA 11T7.t[NT USE ONLY
<br /> D� -'J/• ,. A " �� . 'F
<br /> Day __FLW Il-p.mlon tYr D•E• 'd
<br /> c j Fe or G—A
<br /> -` Addeb:rl CortMrerc..— .
<br /> J'^ n Cos' e n Jo'-CouiO' 1c n-.lta'
<br /> AMa"cave-14tr¢e all coyS a r.—.mrlroo.m�el R.ul]+14relt/6arri<e• .�•Y 41 Y
<br /> P C Do.2009.atgritoa, CA 952'01
<br /> 15C1 E.Rataltm Are F
<br /> •i?' `ZS �C RE AYOIM•T p:- lat)AITT[D R MC[fr/0.Y OAT[ IM.R M'
<br /> OIFO
<br /> ��.,?� .[�,�r�Y.,. ,,5�11111L-i•OC 1 I ,may,,
<br /> - 5..r•x,F,xar-o.a,:a�s�arw•+d.---.....,-sem,...
<br />
|