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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 3040EAST WEBER AVENUE, STOCKTON, CA 95202 DEC 15 1996 <br /> (209)468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> ;Complete In Triplicate) - - - <br /> nMICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOAIR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WHII SAN <br /> JOAOUIN COUNTY DEVELOM�O LE`CHAMER,I��O 115.3 AND STANDARDS OF SAN JOAWmCOUNTY LUB^CIHEALTH SERVICES.ENVMONMENTAL HEALTH DIVMION.. <br /> JOB ADDRESSIOR APN/ V E Y /� � PARCELL SIIZEI'1 1JARU I— G'�LT _1 <br /> OWNER'S NAME EQUAL-OF�J I=N�2PP-ISES �� ADDRESS Q0BOX-62-49 ., Vt'FI/!1, 0� CA90/ri RQVt'tss9, 645-"0L <br /> CONTRACTORD211-;—IljI j. ADDRESS 95D F}OW E ' D IeLc/CSS-9S5-IfEr+IONE I(9L5)3/3-SS'oc <br /> SUB CONTRACTOR Allows,; IMC/ RIONE I <br /> T-TFE OF WELL/RUMP: ❑ NFV WELL ❑ ME CEMENT WELL ❑ MONITORNG WELL/ ❑ OTHER <br /> ❑ INSTALLATgN ❑ WELL SYSTEM REPAIR ❑ CROBB.CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I - <br /> 014—cl mdr H.P. DEPT"FVMP SA_FT. FIRST WATER LEVEL O <br /> n YPE OF R MPI <br /> ❑ OVi-OF-6ERVIOE WELL ❑ OEOPHv61CAl WELL I BOIL BORING B <br /> ❑DESTRUCTION' <br /> INTENDED USE TYPE OF WELL CONFERVGIION e:vttw A <br /> F❑1 INDUSTRIAL ❑OFTN BOTTOM DIA.OF WELL EXCAVATION IV DIA.OF CONDUCTOR CASINO D <br /> :J DOMESUCR'RIVATE ❑GRAVEL P.CKISIZE TYTEOFCASINOWEE PA.OF WELL CASINO D <br /> ❑ RIBUCIMUNICIPAL ❑DRIVEN OEM"OF GROUT SEAL BRCNCATION R <br /> ❑ IRRIGATIONIAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITONNO / GROUT BEAT RIMPEO: ❑V— [IN. CONCRETE PEDESTAL BY DRILLER:❑Yw [IN. 5 <br /> APRROR.DFNN {/ r \ LOCKING CHESTER LIC ISTOVE Rr4 S <br /> RMOIN SED CO"2"M"ONIdR "MET"OD: MUD MEhRY AIR ROTARY AUGER �Y CABLE OTHER <br /> I HE?E6Y CENT"THAT I HAVE PREPARED TWO AP CATION AND THAT THE WOR(WALL BE DONE IN ACCORDANCEWITHBEAN JOAQUIN COUNTY ORNNANCEB.STATE LAWS.AND RREB AND <br /> REGUUTIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICE ;SED AGENT-9 SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18168UE0.1814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPAIQTON UWB OF CALIFORNIA: CONTRACTOTB HIRING OR BUB-0ONTRACTINO 6TONATURE CERTIRES <br /> THE FOL OWING: ' C IFY THAT IN THE PERFORMANCE OF THE WORE FOR WHICH THIS KRAFT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMIMNGATON LAWS OF <br /> CAL ME CANT MUST CALL IA NDURt IN ADVANCE FOR ALL IIEOUmED IR F'�/�A AT 1 4014111423.�OMIlET�``T LOWER AMA PICNUED ,/ /E <br /> B'.M X " 4\-, l TNI. K/ d--/'1000JYYY'� /y Y <br /> ROT PLAN BN—1. <br /> T. NAMES OF STREETS OR ADB NEAREST TO OR BOUNDING THE RnPERrv. t. LOCATION OF HOUSE SEWAGE OIBRIOBAL SYSTEM OR'ROMSED <br /> S. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> J. OIMEWPONED OUTUNFB ANO LOCATION OF ALL EXISTING AND RU SEO S. LOCATION OF WELLS WRMN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.WCLUDINO COVERED AREAS SUCH AS PATIOS.DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOININO PROPERTY. <br /> SEE A,7TALC 46-D SkTE PL_ <br /> I� <br /> /////�//;X////,//'-/'/' //I //�//�DEPEPARTMENT USE ONLY /• <br /> n.PnC.IInn A—. I1 Br /T /''I rk' z l • r - " `� X—' DNa / Z 1- Af ANA <br /> GrnW Imemllun By OMe ( IrnPIYIIM By------------- <br /> DM1 <br /> DMlnptl.n IrnnavRlm RY qq ON <br /> IPA) s <br /> AceoUNTNG <br /> DRILY: AD/ FAC$ <br /> PE CODES FEE INFO AMOUNT RETIRTTED CHECK/ICA%H B BY I DATE R TJIERNCE REQUEST NUMNRI INVOICE <br /> ff , Cc% /L IZ / I 0 C 3 <br /> Pub.Health Serv.-Enviro. 173(1/97) <br />