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,.... .. ..II unir rgrNim <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O.BOX 388,904 EAST WEBER AVENUE, STOCKTOR CA VEi l-W <br /> (209)466.3420 <br /> ROM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEO <br /> ICauFMtf in Trohent6} <br /> APPLICATION Ip HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CON{TAUCT ANWOR INSTALL THE WORN OP6CN6EM THIS APPLICATION to MADE IN CO JIPLIYICE"IN SAI <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE QTANDAR01 OF SAN JOACURN COUNTY PUBLIC ALTN aERVICU,ENVIRONMENTAL HEALTH DMNON. <br /> o <br /> JOB AIX": ,OIt AWNS CITY CQ. PARCEL SIZEIAPNF <br /> OWNEA'S NAME_ I- !'L ' 7 c / <br /> / ADDREas . I1JLfY PP...'f,G•.]C- (.Y'p�� <br /> CONTRACTOR-11 {` !/.I�r c• ADDRESS 14F,6gP^J• uC�J FwOEIE r3-?�!7Z. <br /> 7- <br /> $US CONTRACTOR_ AODRQSS UC/ PHONE <br /> TYPE OF MUIPUMP: `&l A•EW WELL Q REPLACEMENT WELL ❑MONITORING WELL S 11 OTHER_ ' <br /> Q INSTALLATION ❑WELL SYSTEM PEPAM 11 CPIOSS.CONNECT REPAIR ❑VAPOR EXTRACTION WELL I <br /> ❑N.W 0 RF►AIr H.P. DEPTH PwP SET FT. FIRST WATER LEVEL <br /> RG <br /> VPE OF PUMPS OUT•OF-MKWEEL ❑OEOWYVCAL VWLL F �1 r aOfL SORgKl © '�F / <br /> ❑OESTTIUCTION.- <br /> IN DE US 7YIE WFL CONSTAVC ON SPECIFICATIONS A <br /> ��QQ❑{{''M�R/SrNAL �❑R�•}OF�f�N aOTTOV DIA.OF WFLL EXCAVA710N DIA,OF CONWCTOR CASINO D <br /> r <br /> `�I�.LSRMFaTICATTIVATE �DFiy ',TL PACK/CIZ[ Ty PF OF CASNM 18TEEVPVC DFA.OF WFU CASINOEl f p <br /> PUaUCRAUNICIPAI ❑DRIVENDEPTH OF GROUT SEAL / SPECWICAM" R <br /> Q IRNGATIOWAO QOTHER GROUT SEAL&S'TALLE�•D�BY � !! GROUT SRANO NAME -' t <br /> C?MONrTONNO �I I �jGROUT SFAL PUMPEOkR� . ❑IW CONCRETE PEDESTAL SY NLL ETI:1]Y- p J <br /> APPROX.,FPTH /I VL v (((��� LOCKMO CHESTER SOX/STOVE IMS <br /> PROPOSED CCNSTTIUCTIDNlO1fWNO METHOD: MUD ROTARY AIR ROTARY AUGER CASLF OTHER <br /> R NFRF&Y CERTIFY THAT)HAVE PREPARED THIS APPLICATION AN!]THATTHE WORK WILL FEE DONE IN ACCOPDMRCE WAIN SAN JOAQUIN IN COUNTY ORONANCES,STATE LAWS.AND RULES ANC <br /> NEOU AT10NS OF THE SAN JOAQUINCOUNTY.NOW OWNER OR LICENSED AGENT'S WONATUPE CERTIFIES THE FC.LLOWINQ:'I CERTIFY THAT N THE PERFORMANCE OF THE WOW FOR VAGCI <br /> THIS P"Wr is ISSUED,I WALL NOT EMPLOY PERSONS W6JECT TO WORKMAN'S COMPENSATION LAWS OF CALFFOR LA.•CONTRACrQWf NINNO OR"-CVWrIMLTfME NGNATEIR!CERTrrIfR <br /> THE FOLLGW'N0: '1 CERTRY THAT IN IMF PERFORMANCE OF THE WT M FOR WMCH THIS MRMR It ISSUED,!SHALL EMPLDY PERSONS SUBJECT TO WOF'"AN'S COM'w"ATION LAW,OI <br /> CAUFONNAr.' TRIS APPMANAT MUST CALL 24 HOURS IN ADVANCE PW,ALL REGMRm WSPSCTICNE AT I]WI 444-7422.COMPLETE OKAWINO AT LOWER AREA PROVKLEO, <br /> _TInP � L-470 Z�_ <br /> PLOT MAN <br /> I.NAMES OF STREET,OR ROADS NEAREST TO OR SOUNOFNO THE P}OPERTY, 4. LOCATION OF HOUSE SEWAQ!d,POSAI SYSTEM OR PROPOSED <br /> 2,OUTLINE OF THE PROPERTY,OMNG OWENSIo NS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br /> ].DIWNWONEO OUTLINIS ANO LOCATION OF ALL EXISTING RS <br /> AND P4Om*N, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDO FIFTY FT. <br /> STRUCTURES,IWLUD%IG COV'EMO AREAS EUCN AS PATIOS,ONVEWAV6,AND WALKS. ON THE PROPERTY OR ADJOINNO TOPEA•TY, <br /> f r1P //1fJ� <br /> , <br /> Izo <br /> i • <br /> , <br /> ...;.... ...;.. .. .:......:. .. Sir; , <br /> 1 <br /> . o <br /> DLTSJRTMFNT USE ONLY <br /> APFSONIOr.Aeasl.d BY � ' Arw <br /> OrmR`.FR,.elltm BY A�7 GRq r ~I /'•FII11S tIRP,SCM SY <br /> or <br /> CemmrK.:_�G(lt LG1A 1 '� 1 N� WIv I��r S <br /> 0r1 `f'Ltrs WIM.i-� •O G✓tdlt 9r rl� L✓tMi t✓ 1'}'J. <br /> ACCOUNIN ONLY: ALO► FACF <br /> PE CODES FEE INFO AMOUNT P MMITED CHECKOXASH RPCEMo■Y DATE PERROTISamet.REQUEST MIMSEFI INVOKE <br /> t�3lpL4 110 �gc�.0<7 5A? 03at� <br />