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+v^uvl"­V" r Ue VeLUY tRI IIILE,CHAPTER EV I]]5.3 AP2,1))IE S"7 ARit,A:'Tt^9';I.9A ,inA01)IN[�O(/,L,f�JLITV FY/BERG HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVI810N. <br /> JOB ADORE691OR APNI '��1 ��.�Mn -_.-_C1T/! y_�Aa_I,'H �eD PARCEL 81ZE/AF'NI/IoZ RGL'. <br /> OWNER'S NAME Q ._._.-- -_..._ __P ..f_■ �G / PHONE ID 7 �7�7 C� <br /> CONTRACTOR GF ' I1- VRI 1 1 I r ... . _. -. ++rTT'f•:_r a Q , tSs4'R3fs PHoNF S;l.�l e7 7zq <br /> PUS CONTRACTOR PHONE <br /> TYPE OF WELL/PUMP: %VEW WELL ❑ RfPLACEME14 V-TI 1 _ <br /> . F�--h I <br /> ER <br /> INSTALLATION <br /> C�s COHNF TI REPAIR ❑ VAPOR EXTRACMN WELL I <br /> ❑ ❑ WELL SYSTEM REPAIR ❑ <br /> ING <br /> I <br /> sw 11RMpSir N.P. Is!'^'N I'ItMP BET ��Fi. FIRST WATER LEVEL_ p <br /> RIPE F FUMPI <br /> ❑ OUT.OF SERVICE WELL ❑ OFru'R)YBlrnl.vJFli f ❑ SOIL @GANG 9 <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELLCONSTRUC--TION 6PECIFICMTIONS A <br /> 1 <br /> ❑ INDUSTRIAL ❑OPEN 80TTOM D DIA.OF WELL FXCAVATION_). .� ___ DIA.OF CONDUCTOR CABB NO p <br /> �DOMESTICMIXIVATE GRAVEL PACKISQE 4p« */1/Y>TYPF OF CASING/STffLwlv,- _ _ DIA OF WFIL CASINO /(/1/ p <br /> ❑ PVBLIClMVNICIPAL ❑DRIVEN OE)'Tli 6F TIRO):7 SEAt, �.0 _ SPECIFICATID p <br /> ❑ IRRIGATIONtAG ❑OTHER GROUT SEAL 1NSTAII FD RyV_ �t D, OnOIIT BRAND NAMEq'e E <br /> ❑ MONITORING GROUT SFA),f91MFlo: w DING CONCRETE PEDFSTAI-BY DRILLE09YM CIN. 5 <br /> y� t <br /> APPROX.DEPTH ��QCJ LOCKING CHFSTFR BOX/STOVE PIPE S <br /> PROPOSED CONS TRIIC TIOWDRILLINO METHOD: MUD ROTARY _,AIF M7TMY AUGER CABLE OTHER <br /> — <br /> I HE9EBY CERTIFY THAT I HAVE P%FPARED THIS APPLICATION ANO THAT THF WOFW WRi.RF RINE IN ACCOII)ANCF WITH BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND v\ <br /> REGULATIONS OF THE BAN JOAOUIN COUNTY, HOME OWNFn OR I Ir_ENSFO AGFNI'S SIONAFIJRE CFRTIFIFB THE FOLLOWING)'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH v: <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S"­PX P'NSAT20N t.AW6 OF CAtIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTINO SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF �y <br /> CALIFORNIA. HE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL RFOIIIRED INSPECTIONS AT 4200)4440-3423. COMPLETE DRAWINO AT LOWER AREA PROVIDED. -V <br /> I X <br /> PLOT PLAN 10—t.Fk:NeI1. <br /> NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL BUST FM On PROPOSED A <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEM@. 1T1S` <br /> ' I 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSFO S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND llVALXA.--`� ON THE PROPERTY OR ADJOINING PROPERTY. } <br /> Tl e A vw a <br /> 0 <br /> j^ O <br /> VI L� r <br /> No cse <br /> JAN 9199.7 . <br /> 5AN JOAQUIN COUNTY <br /> PUBLIC HEALTH$ERVI,CE5 <br /> IL �E.AL?N.D(V.ISJ. N ...: . <br /> {!fPAR:+v.cN7 vSE ONtY 1 �7)Z ' <br /> Applle.tlen Aeeneled By I <br /> 0tou1(mpenlon By Dole / QZ I'umv IrnPletlon BY_ �Z�F tl/ififlV'`f/'�� —-- DSI• Z 4 9 <br /> D!-I'mtlen I'—Pwtlon(By Date <br /> ACCOUNIING ONLY: i MDR <br />