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0PL LCAT J ON 4 <br /> r. <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH S"I#HS � ;} <br /> -` ENVIRONMENTAL HEALTH AIVIS#ON <br /> 445 N SAN BOX za.TOAQUIo9,N, PHONE (209)46 � �-Y----, <br /> : STOCSTON, CA 9 201 ` <br /> ,> o <br /> I ' (Complete in Triplicate) x <br /> Joaquin CoThis <br /> �• ralt to construct laid/or Sastall FAR volt bsrstn descc*@ • <br /> rtae.Ioequln County far • De <br /> spgllcstloa is made is Cocyea unty Ordinance Aa. 5119 ■ IW &M thelisace vith Sliaise tad <br /> T AWlietiou !s hereby -40 to DRe�Stlatiaas Of San <br /> Joagvin county Public Heelth Services. r <br /> Lot Sire/A1re*4* <br /> r � I <br /> Job Address �6�� �' <br /> rC, i R Phone <br /> Addrest <br /> -Phone <br /> AAA—g Qs_Ll '"� ``tense N <br /> QConitatl0r WELL RfPLFCEMtNT C7 DESTRUCTION LI Out Of ervlce all <br /> rPE 4F WELL/PUMP:_ NE.�WELL Cl OTHER 0 NOnitorla/Yell L] <br /> PUMP INSTALLATION C SvSTEM RE:.tIR Cl i <br /> t PROP.LINE <br /> SEWER LINES <br /> DISPOSAL fLD: <br /> [� DISTANC�70 E�7T: SEPTIC MNK —�— AGRICULTURE WELL 07HER WELL PIT!llUMPS <br /> ter+. FOUNDATION ��� <br /> TYPE Of WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ¢ � ! INTENOED USE Die,of WeN GaM4 <br /> t ' Cl Irsdussrid d Own Bolton+ ❑Manteca Oia,01 Wes Eseawtron <br /> rx + f 0 Tracy Tvae of Caalns_.-- <br /> ,. pOnustlslPJlvan L]Gravel Pace, TvPa M <br /> h �yY y I'r Public <br /> fl Other ll Delta'. D". of Grout Seal �.�..--.--- <br /> fi " � 1 I Itripslton .=—APWO++• <br /> Depth' I I!EsStsrn Surface Soul InNfNKed!qr w-1�N t <br /> sA R Wert'Dons i U Ty"of Pump -- <br /> H.P, State Wart Done !f <br /> Z / *parr fiselin! i.%tarlal a Depth <br /> -;*rJ -, Ws!'r�atlwet►or+ C3 Wall DiematefTtll.rr Itatarisl a Depth . <br /> VYPE 4 S TI WORM: :F1fcW lPFSTAL1ATlON I I REPAiRfApOITInN Tau:! I l wallNbls crit �ALTH� SE�RY�iCIS 4 � <br /> �1 ax r ' ENVIRONMENTAL HEALTH DIV}S16 , <br /> '�' "InHRsatlOfl I,Aa leave ,Rwrrlenes ic._ CAmrrrFcial` ----Y— ,.: �� � <br /> wdnt. I NIOf ba"ww_ 6 <br /> ' j .Nurttbar OI lMlrrq -r✓ .✓ _ Wat*r teEM Apd+ <br /> setae os to a daPth Of a feM: <br /> t sal�� 'CMr Capooitv.-•---- No.CenIpMMl�tta i, <br /> �r+J-t1EEPT TANK. 4 C] TvpalMfg Melhod It CK00 M r � <br /> \3/;PiiG TREATMENT PLY,C1 „ nMrgst Walt tFow`' P143POv LJOW ") <br /> r <br /> td lonpthi" ar <br /> { r t +" LEl,CFIINO ftE +µ+,7�'q Nb i LII Of Nose TO�„r-� <br /> } {, fi a �.WeM��' Founeatbrtfr� OPwsY L fit' <br /> FILTER!EO �. t a Dl+itened 10 naareat 4 y <br /> Nwhber { <br /> Foutitle <br /> s �r�( StlMI•# LI `iHatorK+to rreerast: <br /> � '� yttDl3ppSAC FONtlS, C] . ' ' <br /> r,sr�EC 1'fghby.gtiflq.lives I haw 91 Shn apPat+tlm and that the.wmk wE!be tlona in aeew0a�ee with$>,n JwOta�awah orEMwneea pa/s lams <br /> `�� trona Of I"son JONI Isr <br /> Corm It wdr I dull net!�° <br /> r�r`� ! tietch And a s tfpnatwe peeldla the 10kr k,p:"I tesbfY that 1n N,e per4ormante Of the wart to wlieh+dtls permit <br /> rr 1 s Iflxns,ttwntt.ar.Ile ern ltrCi4 nutrner <br /> as to bat ane sublset to yrprkrnan:a eompmwltion W,"of CoWwr4a."Contraetera Nft a Iprtrsontesrli"0 r <br /> t 1s ispAd.I SW a 00"1►Neaona s*00 to worttnah a eorrlpar+aM` �� s <br /> r+ 6"*wm pones a of the Wert for wnkh this perml <br /> xr ,es0nillaa"'fl*o+rAN I loft-ft L'+I in the p4r wffwm a <br /> G � r• '!r� � tbn taws M CdifatrtLs .i - - - ,' , <br /> `A;`f ayrp(rGtu nOs. <br /> pruit`crE ler at requhad in>1tsOtiom.Cor+�PMt*drawing on nwrNa <br /> TI» <br /> Title: <br /> FOR DEPARTf1tEflT USE ONLY ' <br /> hyf <br /> � sA by F Dau FWW lnapa0 Daesr <br /> ,;f%or GrtMrt Iritpsetlen by <br /> t Plicstnt : ineIt��1 � t rfeer <br /> xn. �oaife[ lpeturn all coplostothPeroI /aervlCsw <br /> F <br /> u1n�.11 P son no".Hae JosqSttsQA 9Stfi r• t <br /> ], � <br /> ` { <br /> ftl;CflviD IIIaATt MRttsT NO U i' <br /> AffOt7kT Sf11E �.AOVkT RtMItTtQ H. -- <br /> 1y`{H Hata � rr��.�w^, {,1 •y}. t 5. - - � k}.. y� <br /> VIr. <br /> 1 <br /> { f t <br /> e <br />