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P.V. Buxam SU4 tASI WtL1tHAVtNUt, AlVLiRIvN, I'A`.fJZUI-3tltl <br /> (209) 489-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICamplere In Triplicate) <br /> APPLICATION IF HERE BY MADE TO THE FAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOG INSTALL THE WOW DESCRIBED.TATS APPLICATION 16 MADE IN COMPLIANCE WRIT FAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OB AMI�� CA • •1 v i • CITY 1^CD 1 PARCEL PREIAM' <br /> T� y 6ya) GAA)+C � Ave • PHONE 0909 <br /> OWNEIP9 NAME A101 ,O` )A yy,A� Vf0n AODRFSP / -s P �j a L1 <br /> CONTRACTOR a //•] ,/0 - D� 07TM' I ADDRESS I O W•M •n�W.*UC, p/p�OLZ I ATONE91Y•/DQ�fT]��'S oxi,4 <br /> SUB COMMCTOR LILT �INL�Y AODRE66 oy 3w if- V-- LTC,�✓ AIONPJPa••.�`w�Z <br /> TYPEOFWELLJPIUMP: ❑ NFW WELL ❑ n6PACFMFNT WELL'• .•❑ MOND ORINn WFl 1.I ❑ OTHER <br /> ❑ INSTAHAT1ON ❑ WELL SYSTEM REPAIR ❑ Cno95SONNECT DFpMR ❑ VAPOR EXTRACTION WELL/ J <br /> ❑Nsx❑Repar ILP. DEPTH PUMP SET_FT. FIRST WATER LEVEL D <br /> TYPE OF RUMP) e <br /> ❑ OUTor SERVICE WFLI ❑ GEOPIYSICAI WELL 6011 ROBING�aJTE• R <br /> ❑DESTRUCTION: <br /> n - n <br /> ❑ INDUSTRIAL ❑OPENRO"om VIA. TIONA 4101,OFWET.EXC.AVATION .•L C IAD .OrcoNOHCIOnCAF.INO NIS O <br /> ❑ DOMESTIGAPVATE 0T�GG�RAVEL PACKISRE TYPE OF CASWGOH EELR'VC DIA,OF WELL CASING PULP � H <br /> ❑ PUBLIC/MUNICIPAL RDRIVEN DEPTH OF GROUT SEAL c E\ SPECIFICATION elyfil ] R <br /> Q❑I IMIGATIONIAG ❑OTHER GROAT SEAL INSTALLED BY �{pp�'/��E PVI I V GROUT BRAND NAME AII&IIdC 7VR' E <br /> 1 9 MONITORING L OnOIUT SEAL PHK•PFn: ❑Y- *,, CONCRETE PEDE6TAI.BY nnILLER:j4Y- ON. S <br /> APPROX.DEPTH 'L �A' Y LOCKING CHESTED ROXIn10VE PIPE hilor <br /> PROPOSED CON6TINCTIONIDRIWNG METHOD: MUn NOTARY AIR ROTAnY AWED CABLE OTHER X G�. • /EO NGr <br /> I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TIIE WDA(WILL RE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> PEGULATIONP OF THE RAN JOAQUIN COUNTY. HOME OWNER On LICENSED AGFNPS SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 19 ISSUED.1914ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMMOATON LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OB SUBCONTRACTING SIGNATURE CERTIFIER <br /> 711E FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF TIIE WOIR FOR WHICH THIS 1'EnMM IP TUR ED.1 614ALL EMPLOY PE SCHIB SUBJECT TO WORKMAN"COMPIPINATION"WOOF <br /> CALIFORNIA.- THE APPLICANT MUST CALL IA HOURS IN ADVANCE FOR ALL REQUIRED IN.P16CT10NE AT 13001 466046]. COMPLETE OMWINO AT LOWER AREA PROVIDED. <br /> sldn X ,�TI11. S•4 AFF Gt D'O!!�Ja7 D•1° '�L _�G.'�Z <br /> AOT PLAN IO,—le Sp•I.1 Re•I. '1. <br /> 1. NAMES OF RTPEFTP OR"DADS NEAREST TO On ROUNDING THE PPOPERTY. A, LOCATION OF HOUSE PFWAf.E DISPOSAL PYSFM OD PROPOSED <br /> S. OUTLINE OF THE M,,,GTY.G1WNO DIMFNPIONP AND NORTH DIGECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> J. DIME.N91ONED OUTLINFS AND LOCATION OF ALL EXISTING AND MnPOSEO S. LOCATIGN OF WELLS WITHIN ARIUS OF ONE HUNDRED NrTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AP PMTSP,DRIVEWAYS,AND WAIX6. ON THE PROPERTY On ADJOINING PROPERTY. <br /> DEPARTMENT USE ONLY 3 <br /> Applla.lInn AcamtM BY Deb I Ara <br /> 0'..Imn.cenn BY 0.1. Rn,p ln.mvS.n 01 '�/1�/•1'��1,y,�/1 Dlu. <br /> D..I,.cuan Irnn.a6m,nr <br /> TV <br /> oR- <br /> ACCOUNTING ONLY- APO/ FACS <br /> PF COOE6 <br /> FEEINTO AMOUNT RFMIfIED dIECK/.'C LPN RECEIVE aY OAT PFN.ITISERVICE ER <br /> REOUEST NUMBINVOICE <br /> o l32U <br /> Pub.Health Saly,-Enviro.173(3196) <br />