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a- <br /> APPLICATIC'I ::A }`IIT <br /> e � 4th <br /> SAN JOAGUI'!.. COUNTY PUBLIC HEALTH :SRVIQRB <br /> EYVid-NUENTAL HEALTH DIVISIDN'' a_,g�.k— <br /> 2801 E. HAZF JN AVE. , PHONE .(209,Adej 01 <br /> P O L ,% 2(.J9, STO--ZTON,..CA 9 701, <br /> - j Pia.rrr ¢7[v�?.�ESL°RR'O:LYS�R PH.MI-OATH �'t t�'9 ':. _�• <br /> (Complete in TripliCial � �s��� , a <br /> AN11"llfoo 1a Mnby sta/. Sell S. Joepu3e Cove" for • yarelt to <C•Iati ud/or S twl tLE, SA' E 'f <br /> '"lloettoo Se ...da in eea0lla to with B Jw ,.In ;omtY Oedios nee 20 Sk9;ted 1862'"'Aba411Li.E�*�, <br /> JaWu10 C"FF holo Sarlfb <br /> as999 N. � c�I D21M1AarI�. <br /> lob Atfdrass /��- �i�J 'P," • n�'jF f 3 <br /> OwMfs Nsma Addraa r.vf�� <br /> ' • E gyp`i.,V yY' <br /> contra _ ✓'of ". <br /> r WELL REPLACEMENT ❑ �' ` <br /> x <br /> Of WELWPU P NEWWELLATION 0 .SYSTEM REPAIR ❑ SEE, <br /> T <br /> r <br /> PUMP INSTALLATION ❑ 1 PR s�. yA y S <br /> SEWER LINES D•SPO AL r y u`u <br /> DISTANCE TO NEARCST; SEPTIC TANK THER a` <br /> FOUNDATION AGRICULTURE WELL 0 t. • 3 <br /> INTENDED USE TYPE OF WELL PROBLEM AREI CONSTRUCTION SPECIFILATIO/IS. R 3Y'y <br /> r O IrtduatrW ❑Open Bonom 0 Manteca Du.01 WO E-ClIn ion v� <br /> oyT of Caalrg <br /> r[j DyMaIK/PI'wne ❑ lwr Pak n Delta DWrh of Grout Sad <br /> A <br /> I I heDlk I:1 „ <br /> INrlpatbn _Appro.. OpM I I Esetarn Sudeca Ssal InaulNd by <br /> T of Pump — H.P. Sur Work <br /> •akbak WaM Gone 0 TYPE —� eeelluA erW Sal. Depth_ nx <br /> We$DasmVCnOn O WeE DurMtn -" TSllar Naurtal A Depth <br /> Dpth _. IT <br /> � 9 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAID/ADDITION DESTRUCTION N� iWSYSIMn 1 1Jt(f° gYgY{{ <br /> Y f — 'r!vx'r'ay�. ` <br /> k IM164tb A Fill RHldance 1'CommarcW <br /> f W�Mr Ikb1kA pol <br /> NumBer of kN^0 unto:_ NumMr of �. <br /> 7G.j�jChafafsi o1.4 to•dqM of�laet� GWclty_ ; 110 G&SS�ErMWRtI�lM+�7 <br /> 51lri;IC YANK Cl TWe/MfO. �. ►�OOnQd Olip01� '"zi`k' " <br /> TIIEATMENT PLT 0 -: - r • '�r9�' �' <br /> DNtsrtu to nesrett We, fourMatan ProP!r!t'LIM A. <br /> s4F.1 , i- sT,�au. 1c ;s*u u1i41 f <br /> *^'= I�E,l u'IINIS�UNE 0 No.A LwVih of INNa 41, <br /> Tolel nplh/kk0 y <br /> � rPr Uni <br /> :- fILTG1 ED 1 17 Distance to rwaraat W41 _ Foundation o0k!!Y <br /> _..'./ <br /> SEEPAGE PITS 7•—DwM --4u—sins % � n end�. _ �[• <br /> SU�F►S..v /LI Dntw:amrrau. -WM�/A� FaunGtwn <br /> Y• :J. i <br /> nO4SPOSAI PONDS 1. . 0 <br /> red MH 11Pl 11*n Ind IMI IM work will W done In accordance th <br /> Ski1,J.n.r.Ee�R!.1 a <br /> "1�! :bI fIMOM'Fortify IMII IrW'Mepa <br /> < :/•WN ca <br /> sfd-r.ptOr nee <br /> I o/fine k , CeunU' _. . <br /> ni s Mwr. rt 1'Oa IM lobrnnp 'I urtlly that In tM gAormencn of IM Yiala,EW _ <br /> Florists <br /> raa ' <br /> Y rPere Fisch chh nMn ,a to becorM wbiwt to wormen`a <br /> k cornpanutwn Iswt of Cal lr ConfMOtOCC 01" <br /> rURas the foEewirg:"I cons" in tN wlnrmanra of H wort for w ich thea nuM•le I. y •n,•ll anipkttly0l eEp� <br /> H <br /> >_ e r Y S Ibn Iowa of Caldoinla." <br /> i for M kb apatbns Crnnpleto drawing On terminal >E ' <br /> 'otr The app6unt mu <br /> Tito: DON <br /> Sgrrd X._._ �F �.4y v7 <br /> FbR DEPARTMENT USE ONLY ti <br /> � Dao <br /> tT y 4'�•`aarr ApPktstinn Attaptad t <br /> or Gn t Irrapctlnh by W�FWI InyKction by. T <br /> Awitional Conxwra: <br /> Ayp13^ant — Ha Cure all coria. Wt Ban Joaquin Cowtt PUD1io Haaltlk . :.� <br /> Berrl<ea, pEYlroOtetal Health Perait/Sarvla a " .�*� a t 1. <br /> s II )1A4 <br /> try,/VAS. 1601 E. A.aelteo Are.. P 0 Boa 2009..Btoektoc• CA 95 1. <br /> �, 'iev DATE <br /> Z -i,r' KRNM'FId', <br /> � FEE NIMDUE MREMITTED AINT AOUNT CASH <br /> INFO ` .,•_ 4 .>v <br /> 3450 s" <br /> n:S r 6' . <br /> 'I: <br />