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WOW <br /> APPLICATION - <br /> SAN JOAQUIN COUNTY PUBLIC 9EALT9 SERVICES <br /> EIIVIRONYSNTAL REAL Cli DIVISI(1N;.:, <br /> 44 N SROXJ ST <br /> PO2009, OC%'ON,2CA,9520142C <br /> _• �ERYTT $I[pIIERQ 1 y�py .......r nAnF I49,Lpp <br /> (Complete In Triplicate) <br /> Apllcatlo0 to Mt, e►ta 1,a 86- ylth S.0—1-1- fou tr Oralnwit tMneenno 549 .,A 1561 W the Ruta• DAOE ReNLt"'he of a" <br /> jow"Co,, to RatNt, !o cap <br /> ,1paEYtA Cor:py NDL< Brr1W 8.nic.a. <br /> { <br /> C,IY <br /> Job Ad&Y <br /> Vf �_ -LSA--<•'f r�¢�"'L Blte/Ac raAgfr-- <br /> Phone - <br /> ;P1 <br /> N.n'e ( �-J et,' � �/[J�` AEE J.Te f'--=f1"" Licen{Clor WELL R LALti,IENT .1 DCB TRUCT ON 0 Out ofSanic. Ydlf WELL/PUMP- NEW WELL ❑ OIHER ❑ Ibnlwriri Wll 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR <br /> DISPOSAL FLDPROP. LINE <br /> j DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES .�- <br /> PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL ._— OTHER WELL <br /> INTENDED USE TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIE(CATIONS Du of Wed(A—ng <br /> O Open!boom O M.ntxa Du.o1 W.11 E.caYAbon <br /> ❑Yr -toTYW of Ce.ip_- svxi'j�`AWna <br /> fl Dm+lKl Ial"ntf 0 GnW►aCA t ;Tom; Depth of G'oul Som' <br /> PWec pep _ TYOG oI•DtpY <br /> fl Ou«II` <br /> f' _Awoc.Depth I I E611w, Sudan Sul installed b <br /> 1 1 bgnMn - Suu Work Dov <br /> RRNW W.,DoM 0 Type of Purtp N.P.._. <br /> t lNalloS IIAMr1A1 \ DNM <br /> Wed DaevMGNolt O Wad Dmalvel r _ <br /> i Depth 711Ur IYter L pytD <br /> t ESTPUCTtUN I INo uptit W.u2 perrmmtd i1 MddK <br /> TYPE of SEPTIC'NORK: NEW INSTALLATION I 1 REPAIR/AOOITIO awlaWe w+lhin 100 I«L1 <br /> that""ion of fa,, 1141/ tc•Jk- CgMprcial_ Omar <br /> Nlantar W SYrrp Irrao:•--A- NumDM of t�A�- wow,tat la droUl i <br /> Chowww of foal ro•depKt of 3 bt: — C wciry No.Ccmo•'nmulu <br /> SEPTIC TANK O Tyq/Mip Method 0 klli:p«>I 3 - <br /> t PKG.T%EATMEMT PLT.0 <br /> Found.t.�-n 1 PrcpartY LiM <br /> DWartGa 10 rtaareY: Wed�Y <br /> N o1 Yru. <br /> Total Mrlgll•/Eue___- r- -' <br /> LEACHING LINE Ll No.E <br /> L. 1�_ Property Late- � <br /> i <br /> FILTER BED <br /> 0 Di"Aw"o,a nw«c WM -> n_ founaalan <br /> 1•, SEEPAGE PITS 11 DNA sue--- <br /> Prope'Ty Lirw._eL.�., <br /> ' wfpy LI OielYlca to nw«r. WON 1f-- <br /> DISPOSAL PONDS O <br /> 1 Yarepy<AAYY 1M1 I haM datWtl tef appk0a[KM and that 1M wprl adl be Ern..n x<o,"Me with BM lO.QO'n GDunry adMAfKH,f•ale I.wt. .'• <br /> P.A.MM rag'A krona of the San lo.Rwn Couay that mAnc.of Its work Io,M Iclt thl,pfmkl I,v ufd•1 Mai:,..,. <br /> Nome o,Ahaa r k w*W awll',IMYMtwe owl'rf tM'060Y ng "I GNLfY In IM« u 4.pl CtM1gnJ."COnt,xl N^.,,... <br /> ahnw,Ant,per•on YI aVG11 MrVMr«to wothe Wboct 10 Wprkrnel�f cOTpfn[alian wnO <br /> doww) ro Yqr\mefl'f COT4'" <br /> tand.IM Ipk"e g: -1 GMfiM that n that pedonnMl<'e 04 IM Work Id vhl h Ihi4 W,,t U iMu1d.I eh&A.rnPIgf Par Ix <br /> n YM of Celtomle." `„, •y� au ton .DOrn—Duu /anN. <br /> The aPok<wl M 1 <br /> Data! r l <br /> -__ <br /> 5pMd KTM: <br /> DEPARTMENT USE ONLY q q I Z <br /> oat. Ans, <br /> AppYcltOn A<cepuE by �”� 'Zy' <br /> Data <br /> PK or GlOOI YYrpattl0r'by -- <br /> __ Dau fm.I <br /> AddliaW Conv.wv: <br /> Aypllc Ant - Retura Ail cuDla to; RA r 1YOAIv"[� Health Paruil/pa nllcnw lc of /1 <br /> .45N San <br /> �A%6 UN11INin[P a,Z[�Poa IK[C WIpYaY^A O'.]UOAiE Il11HU N0. !i <br /> Elf A.gl1MT Wt CA N <br /> WYD a'-'YYIR l0 9 9�--�io�- <br /> 0 <br />