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,i <br /> APPLICATION j <br /> SAN JOAQUIN COUNTY PUBLIC HRALTH SERVICES ' <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN :OAQUIN, PHONE (209)468-3430 <br /> P O BOE 3009, STOCICTON, CA 95201 <br /> v Dcag•IT RSPIRE vT:aR FAOY DATE ISa08D <br /> 1 (Complete in Triplicate) <br /> } <br /> jApplle.tloe is bil ly w o to al Joal Coun[r for . Fail to <ov.crvcc uE/ 66or in.tall he TuleA wrl bell a bonne of Thin <br /> ( applldtim 1. o 1.NeAltdiBer5ldth 9An J04i County OHIO. No. 549 Arra 19 And the ill ReNL <br /> ` Joaquin Count' AA♦� !/ r( .�[ � ��� <br /> City�r,�(�� <br /> a� / � 111 Fi ttt uFJU-JL4- / Lot site/Acr-W <br /> Job Andrew, --'I �Q _, ,..��• TT s <br /> Piton ` <br /> Q4 POF db.e, --�- r <br /> Ownw'F Name <br /> Attest <br /> LlCeme No. phone <br /> jilinilla WELL REPLACEMENT ❑ OFSTRUCTION O Out oTNEW WELL O OTNFR O / Hall O 7F WELL/PUMP: SYSTEM REPAIR LlPUMP INSTASIJtTION ❑ DISPOSAL FCO._— PROP.LINE �.SEWER LINES ryT1/SUMPSit <br /> NCE TO NEAFFST: SEPTIC T/.NK AGRICULTURE WELLOTHERWFC`—FOUNDA nON <br /> TYPE OF WELL PPOBLEM AREA CONSTRUCTION SPECIFICATIONS te D1-1 W84 COW* JF ea t. <br /> O Open Sol O Maelete <br /> INTENDED USE Dun.of Wal E.ervNion Sy<Nkadute '"d` � <br /> O IniurtrW O TntY Type Te of C" �! <br /> EI Gone c/P,,i O GnvN Pace Dal el Grout SON TYW of lo - r <br /> 171 01n Il DNu <br /> I'I hrolkAMot.Depth I I Eeneln SuHad SAW ImuI1M ov ' <br /> ' I I IrtiyNonState Wipe Done— Il <br /> U Type of Pump H.P. <br /> RepW Wora Don. sea lE leered Alf Depth , :X <br /> Was Dervinc lbn C Well DW iff Piller Hait ie] S Depth 0, <br /> Depth -- pemW nd K putesc eeww is F <br /> rvaNwN Mtnln w <br /> 9pD 1w1.1 C`t k. .�,/' <br /> TYPE OF SEPTIC WORE: NEW INSTALLATION REPAIR/AOOITICN I 'DESTRUCTION I f INe teplk aptem <br /> O.Mr ti <br /> IdlWtbn tAFS wrN: RwIMrtH CoivmNcW_ � ♦- `, i s''; <br /> 2 <br /> NVrnWr o/ni al of pw,eome Water"i depth <br /> Charities W eM ro e Otpyen el]Iwl: NO.CoRlpertrnenN 4, t <br /> } SEPTIC TANK <br /> Type all 75 WtnoO _ <br /> Pill TREATMENT Pill O �_ FouMAtbn A--- PropeM <br /> Dhtaroe to MlrwC Will q <br /> — TolAl length/We ; <br /> 4 LEACHING LINE No. a Length 0I IN! him Uhl <br /> y <br /> Dletanaa to h0all WNI.,��� Fou" ion jttY t <br /> 1� FILTER SED dt� ' <br /> t51»— NumWr a� <br /> } sill PITS I I Depth Pioneer,Lkte <br /> ' SUMPS <br /> LI Distance to dereN: Wee Foundation <br /> DIS�SAL PONDSe <br /> O <br /> 1 Mrwy tMIN that I hal I>'eWled Inh applidtbnoldthat IM work will W don M FeewOer!d w+lh San Joaquin tountY ortWtaR9M.par 4erP. �.it/ <br /> rvhe end ahri"'ione el the Sen Joaouin CounV' _ <br /> 1 Home owner a Rce^aOf he Son Nputuu drtilye tM lolowirp:"1 drtlfy inti In tM peMamance of lfte ttroM1 la Y,111Cn RM Pentyl a,heuM.1 eRY 1101 <br /> emNoY any P,,,'kt euchdtrrmtert wt to phi the h�o sults oto ' for tvihich comp1�to pat nt o New0 I NUR emday poison,etrDYert ttler.IttertwtRerttOatlaF �s` <br /> dnNlw The Iowvh+0: .. <br /> ton to.of CNllarn"i on revert Fide. _ <br /> ery�r�ueo(M rep��l�y)�apPctione.Compote bewinp <br /> TM.Rola I cal t <br /> l ) G �C `T I✓�rv�02� Deo: <br /> The S 0 <br /> Sgned <br /> 1� TMENT Ufa ONLY <br /> (� A Dau AM �/yS /�q,,//�9t� <br /> AOpNulon Accepted DY 2 " YY Dart / / <br /> Date I"Irupecton by —T/ <br /> ►R W Grout Inspection by �— <br /> q�tsJf/— <br /> AOONIaW eorMrMntR 11 x h s r reetMeewre�■resat^eF��� <br /> ApDllunt - Return ell cop ve [o: 6ev oeeulo o n <br /> 4451 BonaentAl BeLLta Pa Belt 2(Xill pea <br /> ' ea6 N gee Joeaaln, P O Boa 9008. 6ttn. CA 56901 <br /> 1 DUl A <br /> ARECENED 11YDATI IIPMIT'ND. <br /> ill MOUNT NM)UNT 6FMITTFD ' CASH C� <br /> INfO / IN — <br /> ,lNufeua.rr.0 co �ZfS�P1 <br />