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q+ APPLICATION �'/ d�6/i0. 20-2?21-r,3
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<br /> SAN JOAQUTA COUNTY POHLIC HEALTH 3BRVICfiS9
<br /> ENV1RCNfl?4(TAL HEALTR DIVISI .3'01 aati.r "�-`
<br /> 445 N SAN JOAQUIN, PRONE (9'09)48 . #
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<br /> P O BOE 2009, 9TOCETON, CA 9
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<br /> t`- (Complete in Triplicate) FACIA
<br /> APplieotlm Le hereby uredo to San Ju9uto Caunty for . perelt to coMtruet card/°r 110 l a rXvdT!'R a of ben
<br /> eppllcation L trde{nie 0*
<br /> eay.011quPlw vith "A JARV'xin Countyid Ordinance RP. 569 a1 11YYVLYp}I�fr
<br /> Jaequin CowtYAD�l �/7'�7 n• we• �1
<br /> Job ASdraa ( _-- car/S�4—�—� Lot tlt a</Acr,ra{♦ r '..
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<br /> Cr eerett p— �' ♦ License NO.-•♦a+2-�-PM'u `L L? ,Aj"t�,,
<br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLAC MENT.f1 OESTRVCTION O Ou�c o�fge1�tpr1eNS urJ er
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<br /> MJM INSTALLATION ❑ SYSTEM REPAIR El OTHER Jd ItiTesr
<br /> I. �.. - -PROP.LINE
<br /> DISTANCE TO NEAREST: DEPTI TANK 3EWFR LINES OTHER ILLD.�_ is6SIC
<br /> `c'• - FOUNO TION' - MTS/SUMIS jo. ♦ tEt°
<br /> _ AGRICULTURE WELL OTHER WILL
<br /> IN'•'IOFD USE TYPE WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS y":f✓mpA /!r
<br /> '`�" CI trMuiaiN ❑OpN Bonem 0 Manteca :.Ole.° eD4.o/
<br /> I Well Ercalallon
<br /> Wen GAillq ,
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<br /> 141 Pubk 0 Other Il DNu' _ DaPih of Grout Ssal ♦ ' 6
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<br /> WORK.. .NEW INSTAr.UT10N REPAIR/ADDITION DESTRUCTION I I a`ala.1h,n m200 fNl�N NNPIPYc NwY^IK (Y
<br /> ��� ° Wlf eeN1 ' RNMMce� CarvM1JrcNI_ Other
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<br /> r�A,y+ 4❑ ,' Length or i"I _---
<br /> Total Mnpth/'ire
<br /> No �g
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<br /> P.h,ation PlOpatY Line
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<br /> IN,pplkatbn anO nMt IM wort will M doM h accordance vath Shen JoeW,n e '�ee4hve.-y * .. 4 +y
<br /> ran IM Mn Jowntln Cwnty
<br /> aBMi' '10malNa brut"the lofbw,ng I cantly that In the Wr/pm'n<e of 1M ward( v.HIGI •,t
<br /> +' M weft rrMlvlRr ea lP bNOIM taboo to wwk m 'I.eompe,Ietw laws of C'4lorrw Cbnva<mra Ilninp a
<br /> :,3 34 •r canty tMt Im pn'_WOVA'ance Of 1M«o,F to,w,Kn can P«Init i't+.wa 1'"Ilrnw'PY wraPM
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<br /> �FGIPARTMENT USE ONLY
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