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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O, BOX 388, 3154 EAST WEBER AVENUE, STOCKTCK CA 95201388 {209} 48$.3420 NOWREFMABLE PERIIR APPLICATION IS HERE BY MADE TO THE SAN JOAOUSI COUNTY FOR A PERMIT TO CONSTRUCT ANDM*WALL THE WORK DESCPWED.THHS APPLICATION IS MADE W COMPLIANCE WITH SAN -A—COIAITY DEVWMAENT TI TL1E,,�V CKApi;M W 11+1 5.3 AND TH STANDAIOS OF SAN JOAOLIM WjNTY PLtB X HEALTH svmv CEs,ENTAL HEALTH DMI14C C JOB ADORESSPOR AMM--b 3 y /1 -� 1 C `'( f 5_1 r-e --T- aw`5�{T^o c tQ o vA PARCEL StmAPN, OWNER'!NA..E V✓p 5`7 `l A`, 1 ✓'o�'�r ( i t,� AODRE84 6 J� / lM.'F,�f` C lad/ fi,, 5 I c:i'1 i�!..,.PHONE, t y -l 0 7�j coNTRAcroR voNCY r+v Fillelr AYO-g ja 1, r If05 w-Mare 1,,14."5/mnuc.6So�7 PHONE.QS6-o;L6y sua ucm-- Z(�IZ PHONE Y 6 9-C19&5 P TYPE OF WELLIPUMP; ❑ la wEu ❑ r"lAcmww WELL ®M owropow%, L S 15 ❑ OTHER ❑ INSTALLATION D WELL SYSTEM REPAW Cl CPDMCDNNECT!@ANT O VAPOR EXTAACTXM WELL, 1 ❑N.w D P-,.k H.P. DEPTH PLUP BET PT. FIRST WATER LEVEL O (TYPE OF PULm ❑ otn.or-SERVKYwELL ❑YEDg1YGICAIMISLI ❑ So1LBomm ❑CwFral1CTIOw INTERDED USE TYPE OF WELL CON TION SPEC6iCA /I A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION S DM.OF CONDUCTOR CASING I/ rT D ❑ DOW-WrICJRVVATE ®GRAVEL PACK/SIZE TYPE OF CASINO/STEELA-M I �C INA.OF WELL CASINOY�J D ❑ R/BIK.N.M/t11CIPK D DRIVEN DEPTH OF GROVT REAL I V SFECPICAT)ON ' I1- R • tmGAT"IAG ❑OTHER GROUT SEAL INSTALLED BY GR OUT SPAM NAME I y4 0 A c+W e1A E © mowuom G GROUT SEAL FLMAPED: ❑Y.. ©13. CONCRETE PEDESTAL BY DRILLEIF❑Y.A E3&% S APMOX.043" - LOCIUHO pKSTIM BOXJSTOVE PIPE 5 PROPOSED CONSTRLX:TION/DRILLMO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEVESY CERTIFY THAT I HAVE PREPARED THIS APPLX:ATION AND THAT THE WORK WtU BE DONE IN ACCORDANCE WITH SAN JOAOUNI COUFITY ORDINANCES,STATE LAWS,AND FAR-Ell AND IKOULATIONB OF THE SAN JOAOLNN COUNTY. HOME OWNER OR L)CENSEO AGENTS SMATURE CERTIFIES THE FOLLOW04G:'I CERTIFY THAT IN THE PFWORMANCf OF THE Vmw FOR WHICH TWO PEISAIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WOWMt^WS CDWBISATWN LAWS OF CALIFORIAIA.' CONTRACTORS HWOM OR VJO-CONTRACTING SIOIUTUM CERTIFIES THE POLlOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE V40M FOR WHICH THIS PEAWT IS MUM I SHALL EMPLOY P&MOIIB SUBJECT TO WOPWAAWS COM PINGATION LAWS OF CM00110 IA' THE APPMANT MUST CALL 24 NOURS W ADVANCE FOR ALL RIFOUIRED NHIF'NCTRONS AT ON)4M4b422. COMPLETE LTNIWNJO AT LOWER AREA PROVIDW. w+•+X, 1 �(.t TIII.52 N I, S PeFf G o[0 9 ►5T D«. ` 1.7 -17 /LOT RAN 0—t.S-io Sol. 'M 1. NAMES OF STILETS OR ROADS HEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SVBTEM OR PRIOPOSED 2. OUTLINE OF THE HIOPERTY,OWING DAAENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STM)CTURES.WCUNDNIO COVERED AREAS SUCH AS PATIOS,DRVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING AIDPEATY. . .. .... .... MAP Diel BACK .................. ..... ........... ............. ................................ ...... .............. 0$AIRMBIT tpE ot4r 4 APp17aFfbn A...ol.d By 01.10 W-P—Ii—BY Daft ftrw r.PGWA R M O.I. D—.—"—YrP..den BY Dow ACCOLINT11"ONLY: AJW FACJ IK CODEC FEE INFO AMOUNT PdANTTED "ICA&H REC9VED NY bArkE REQUEST NLSISS6t PJVOICE u;i;r. OOI S/ O1Z3V-3 /23