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APPLICATION
<br /> SAN JUAVUIN COUNTY PUBLIC 1I1iALT Cj �r--�
<br /> EWIRONIEF.NTAL 1IFALTII DIVII,Qpj���t�lI
<br /> 445 N SAN JOAQUIN, PliONE (209) IJ6►� 40--
<br /> P O BOY 2009, STO(ETON, CA -
<br /> pAI�nIT
<br /> (Camplet2 in Triplicate)'
<br /> ADylLtatloo
<br /> is Oerc>a nada to!eta Jc+quia Cam ly or • urs:t to Cong3. .and
<br /> Sns" tt,etRules ande Rg Cjlat,.ona`of T n`
<br /> go.
<br /> ttrplioati0o
<br /> is a"* in cosg1lwmc* with baa:oaduln County Drdsncr,ce o. 53.9
<br /> 5 Y ,nd 196Y
<br /> JwRttla CouatJ PuDll/e Be—altb Sgr'ric.�w1. 1'1',0,j
<br /> --
<br /> ArsMsso �J I l L /7:,!�/J a..t._�.---- Coy %J/,, Lcr atze/.1�reyte
<br /> I G .7F Twnt a y
<br /> Csntrathx _
<br /> verse No.
<br /> PE Ox WELL/PUMP NEW WELL O WELL REPLACEMENT TEMREPAIR " OESTRU�TI ER it U o: Serving uell
<br /> --`� PUMP INSTALLATION G SYSTEM REPAIR J
<br /> OTTER G monitoring ❑
<br /> SEWER UNES DISPOSAL FLD. PROP.UNE
<br /> OtiTANCS TO NEAREST: SEPTIC TANK PITS/SUMPS _
<br /> FOUNOATION AGRICULTURE WELL ___ OTHER WELL
<br /> INTENDED USE TYPE CF WELL PROBLEM AREA, CONSTRUCTION SPECIFICATIONS G a.of WaN Cawnq
<br /> Irt6vatnst O Open sonom C7 Manteca Out or WN Ezcavatan —
<br /> --- Spec,lcaoons \
<br /> T1 oon»•t.:lPrlwm o r.,4 Pact Type of Ca-9
<br /> C7 Tr,cy ----- Type of Gras
<br /> PI Ptak CI Otlw (l 0@11A Depth of Grout sg,'
<br /> h I I Eastern Sumacs S"Insi,w.d try
<br /> 1 1 Irrip•tr0yt --Appr(n.Dap,.• _ ..
<br /> A"wk Vvoet D m• U Typo of PUMP M.F._ Stats Wort Dons—
<br /> O WM Diwnatw basun,{ Notarial l Depth �.
<br /> woo a7asYtseriin riller Material E Depth
<br /> Depth
<br /> YPt Of stpriC WORK: Nfty N:SIALLATION REPMRrApOITtOn I I DESTRUCTION :A#�ootv�.n 2W Iaet I p i'
<br /> Irt•t1l�atiDn ai pis. lla•r6Mo•� tpt�u�— d,« .
<br /> _ l —
<br /> «�,iry moo: tNur'nWr of laadrooms
<br /> '/'�_w,t«tats dgP+n
<br /> cItter6com of W m s S dyv'ftwc
<br /> a Itf-c Cop-AY v.' �i No. Compan^rnn �— v
<br /> SEP=TANK / Ma:hod o/019Psi1
<br /> PKO.Tt11tATN"i PLT.O
<br /> _ CI•ience t0 tMarsai= V1i'N.s.]S.[` faw,datiext._5l-_� Pro."ony L,n° r
<br /> 11A1 LINE Q N0.•Lrnt7th OI k" Tutal kngtn/Mia .
<br /> ;- Q Distance U newest; WN__G°— fourwatan Property Lino I .
<br /> liLTEA SEOi
<br /> 110m f PETS 11 Dsptr Suer Nun t er_
<br /> Foundstrcn Property Lina i
<br /> LI OiwAnca W p••rs" Was - -- __
<br /> tr �_pfSIOSAL'fCMJS O
<br /> F - ar.-4 tfat the,ti�ork w,t W dowse n actuo+nu with San,lOegt.:in ca,ruy ort.4nanGq.sUw kwa,and
<br /> f Amply*arch that I Nor•prsp•red tftl,+ppb:b on i -
<br /> tsrlia e,.td wouletiom d the'San.60"w,09%wty I cerbN that in the Psrtormaus of the v.�ra for wheels tfus perrT'R s suNd,t char not ..
<br /> or k4nsod a cwuf*s lira I,rfowwv:
<br /> iiatpio► 1yl pitMort aNC1t^�� Ws betOrtts•tt�loct W worfnan's conpero+tion[ma of Cain-:+ra."Gntrsctors 1,irirW a wrPca+tractinD sign"U" _
<br /> 0•t)�irla t%&f ,Q;'y cw*y tJnst K rix parfrumanca of tt.0 work for wh}Ch this pormt rs*..Jed.I,nai w*pro'i panort,ou0pct p workrr,an'g
<br /> c.ynpana•- .i
<br /> %Im Iowa of C>rl10mis
<br /> Tt» d C0.,r,pleta drsww,p on reverse a d.. l
<br /> c•�Tor d aaq,xs Trus /'{-✓,s`I Data: 3— 3—'2
<br /> `I
<br /> sie.t•. f
<br /> 9 FOR DEPAR71MEP"USE ONLY Z
<br /> DataC.
<br /> p n Aon btr.
<br /> .' Firti htat+ent+o^by paw
<br /> -4 M OWA u _
<br /> Adaf�ipwd CuntR+•es+t
<br /> ;lApp)leut —As tarty a21 coplas It.: baa Joaquin Co"ty Public Bealth Se�rvlcns
<br /> a - Dv tarAentai Bealth Pewit/Sx rvScea7s
<br /> . 445 0 Ran JoaQutn, P O BOA2(NN, Sttn, CA 87501
<br /> fE! AVDNMT Dtx AMOUNT REWTTCO
<br /> IL RECENEO iY DATE �R)Aa>w. .
<br /> 1 -io
<br /> `}• .�� S3 3sr1,
<br /> .«ilw wr.•,. i
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<br /> 4. �..,..,.�. n,....;;�_;;.:'I�.lesa.'."aw�".'+.n:J,,a;dYL � 'r.• ....�7 .. ....., ... .
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