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SA%oAAQUIN COUNTY PUBLIC HEALTH SB,4CES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WESER AVENUE,STOCKTON,CA 9&M <br /> (209)468-3420 <br /> 19K E MADLE P *Wm I YEAR FROM DATE NOUN <br /> API7JCATION M NIEIIE SV MAGE TO THE SAN JOAq,I„ Mw*b%(11 TrWbdo <br /> JOAOUMN COUNTY DEVELOPMENT CSV FOR A POW TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TMS APPLICATION IS MADE IN COMPLIANCE yy,T„SAN <br /> TTfLE.CHAPTER 0-1116.3 AND THE STANDARDS OFSANJOAOUIN COUNTY PUBLIC HEALTH a/ERVICEe.ENVEgNMENTAI.HEALTH OINepN, <br /> Jos Ao0lEstrOR API/ 115 1 Q'-' C 1 i f B/y C"07'' ��lPARCEL N2E/APNP <br /> owNEll'S NAME r•I o A -1 F �n. U '`"p R')Cl <br /> ADORES �� CO.-l- . ci Ih Al� P11-/J <br /> cONTRACT011 D T• n 'w ^ 18"O� W >til al d.• oa <br /> sRrs CONT"ACT011 i�' E 1 / ��ADDRESS <br /> ii 22''LL CC - LN:._ 22 7 F r1E 6�02 b b <br /> ADDREq�J.7F ^ �,ArnA 1 t�� I ot2-7 ► 95j aZ V <br /> "nntwo FA nh <br /> —TYPeQF 13 NEW WELL ❑REPLACEMENT WELL ❑MOMTORMN WELL, ❑OTINEII <br /> ❑INSTALLATION 17 WELL SYSTEM REPAIR D CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL <br /> 13 J <br /> Nw�r OlMpdr H.P. DEPTH PUMP 8ET FT. FIRST WATER LEVEL <br /> rrvPE of PUMPI o <br /> 13 ❑OUTAF-SERVICE WELL 13 GEOPHYSICAL WELL I SON.DORM <br /> s <br /> oESTIN/CTION: <br /> -. m ^^ wIL <br /> INDUSTRAI OPEN BOTTOM OIA.OF WELL EXCAVATION_ QL-.1 AIC. DIA.OF CONDUCTOR CASMO_N�If p <br /> ❑DONBSTIGPRWATE ❑GRAVEL PACKiwe TYPE OF CASOM19TEEUPvc N'A DIA.OF WELL CASINO_ <br /> 11 PIISUCII Al1lNGPAL ❑ORVEN DEPTH OF OROUT SEAL _�- N'ECIFK ANON L-A O <br /> 13 IRSMAmwAM ❑OTHEII R <br /> GROUT PEAL INSTAL SV �( (� <br /> w MOMTONLYO GROUT BRAND NAME <br /> c �C,. GROUT SEAL PUMMO. V� �W� CONCREI PEDESTAL MV ❑Ns S <br /> APPROX.DI'TH 5 n -T�.l'} MQ- LOCKING CHESTER SOX/.TOVE PIE�� <br /> PRO1�CON{TIIICTtONNOAIlINM METHOD: MUD ROTARY AIR ROTARY AUGER CANE (OTHERS C O <br /> 1 HEMESY CO RTI"THAT 1 HAVE PREPARED TMS APPLICATION AND THAT THE WORK WNL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCE$.STATE LAWS.AND RULES AND <br /> "EMULATIONS OF THE SAN JOAOINN COUNTY. HOME OWNER ON LICMD AGENT'S SIGNATURE CERTIM8 THE FOLLOWMN:'1 CERTIFY THAT IN THE PERPDpWANCE OF THE WOR(FOR W/SCH <br /> TNM PMW M OWED.I SHALL NOT ENPLOY PERSONS SUBJECT TO WORRMIIN'S MIAINSATION LAWS OF CAMMMIA.• CONTRACTOR'S HNSN18 OR�NONATURE CERTIFIES <br /> THE POU:OWMMS: "I CERHFY THAT IN THE PNS'ORMAANCE OF THE WORK FOR WHICH THIS PERM"le NNNED.1 N1ML IMAPLOY PERSONS SI/SJECT TO WMRN AWS CONPNNATION LAWS OF <br /> CALM'OINMA.* APPLICANT MINT CALL IQ 1 URS IN ADVANCE POR ALL PROU MO WSP TIONSATjaM 4*V44=. COMPLETE ORAYyIp AT LOWEIR AREA PQIDVIDEOs/�+ <br /> el�.a X-� Tle.� �P t7 Q a'o ►� DM,_ 1—1 J^ / <br /> PLOT PLAN Wrow N SooW$ads •I. <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOURNOMPG THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED <br /> Z. OUTU E OF TIE PROPERTY.WANG DINRNSIONG AND NORTH OMWn N. EXPANNON OF SEWAGE DISPOSAL.SYSTEMS. <br /> S. OIAfNPNOIIED OIRUNES AND LOCATION OF ALL EXWTM AND PROPOSlD S. LOCATION OF WRL@ VWW RUM OF ONE MNINDRED FIFTY FT. <br /> STRUCTURES,NPCL.UOWS COVERED MEAS SUCH AS►AM ORIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTYsEac . <br /> W: <br /> MAA <br /> DEPARTMENT USE ONLY ^1 <br /> .0461 <br /> 1 <br /> Pune MrPMRIon By, Diu <br /> Downw0m MMPwwbn a Date <br /> Co me slit- <br /> ACCOUNIISM.DOILY: AID# FACT <br /> PE COMES My" AMOUNT RIPWTID CHICKPICASH RMINED MY DANCE FSINLIT1MERVICE REQUEST BUMMER INVOICE <br /> YaD W-1 <br /> 1 JV <br /> Pub.HOMMh Se1v.-E nviro.173(1 AB7) <br />