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SAN JOAQUIN COUNTY PUBLIC HEALTH SE'►,_,�ES ENVIRONMENTAL HEALTH DIVISION P.O. 80X 388. 304 EAST WEBER AVENUE. STOCKTON. CA 9201.388 R09) 488.3428 NON-REFUNDABEt PEBUff APPLICATION 16 HERE By MADE TO THE DAN JOAOUM COUNTY FOR A PEKlWr TO CONSTR=MWOR HNSTALL THE WORK DEWFISED.TM6 AMMATION 10 MADE IN COMPLIANCE WT�QAA JOAOULIN COUNTY DEVELOPMEilf TTLE.CNRAPTER 0-1115.3 AND TIC[STANDARDS OF BAN JOAOUIN COUNTY PUB=HEALTH CZR%MEQ ENVIRDNMENTAL HEALTH MVICION. .loo ADORESNOR APNO ;SS e—O�— 1 o aC I� _ �, -I'.r a.cy rANxEL LQEiAPNP amts"NAME D t V;ale.•,� tiD Q�tl'f�"`'"-� Gor po.� �A�ONIEss 360o Prtt✓tr:� Ave.�Sc-6-Ct"&- wRONE 0 COMPACTOR �eo r1a�s,:X Cs-.Sul��. }s {rr+C . ADORES@ 100 e,v e 5 4, S• �^ °u•� t� _,"Ngo (- f) 9 V o 4 y_ am CONTRACTOR C7rts9 br;f��.aq ADDRESS 1So HOWE ?J.H -4;OCz LNC, (4851`S Cs,e� PHONE/313- SBoo TYPE or wRUPUMr. ❑ NEwwPJL ❑ Fou cLBRE a WELL ❑ MoMr000m waL s ❑ wmm ❑ BNSTALLATIOIII ❑ wmL Dvarnm 11EPAta ❑CROgtOMNECT WABI ❑ VAPOR uTpACTm WFLL/ J ❑ TYPE OF PLNRP) New❑NMpdr N.P. DEPTH PUMP s2T T Pr. F WATER LEVEL O AA 0 ouT4w mca weal ❑GEDPHYBICAL WZ LL A ❑ moL COiCYO , a �OESTIClCT1DN: / ��-�� I Hw-1�A,!'1t�J-12p1,M1t�"13,N.tu!-ly +MW-IS,Ht✓^11,1nw-ta'1�w-L8� �1W-19��1-Z� .-tw-21 N F^(.+�'CZ I Nrt3N010 USE RIPE OF WRLI. CONSTRUCTION•PCCWWA'nOMB A ❑ vtmmmAL ❑oPw1 wrroM DIA.OF-WELL EXCAVATION DLR.OF CONDUCTOR CA== O ❑ ooMEDrRCAmvm ❑RamvLL PA=mzE TYPE OF CAgNOMTEV-VVC OlA OF WELL CAGNO p ❑ NKMLICAAROCIPAL ❑DRIVEN DEPTH OF GROW SEAL oS LYMATION R ❑ RIR usnowAs ❑OTHER - @ROUT CEAL MISTALLMD BY ORDUT P' ND NAhC2 E ❑ MONtTe»neto RLRour em RfMPEO: ❑v. ❑N. CONCiL erE F%mcrAL BY mum❑Y. ❑N. s APPROX s1sTN LOCKNIO CHEWER COXffMVE RAE a PRMO=OONSTRIM?L01iIMMIA NO Mfr"*W MUDADTARv Ala WTARY AUGER CAm oTum 1 HF•MESY CERTIFY THAT 1 HAVE PLETARSO TMs APPLICATION AND THAT THE WORK WALL SE DONE IN ACCORDANCE Wrr"a"JOAOUON COUN►Y ORDINANCES.CTATE LANK.AND MEG AND REOULATIONS OF TW SAN JOAOUM CO%WrV. NOME OWNER OR LICENSED AGENT'S SRONATUIE CE nM*THE FOUDWINO:'I C21TPPv TNAT IN TM.E I'MOFMANCE OF THE WORM FOR WRSCM TLSO PERMT 19 ISSUED.1 SHALL NOT EMPLOY PERSONS SUOJECr TO WOREmN'S COMPEIN aTLON LAWS OF CALIFONM4L• COPRRACTowc H"mm on cua coNTRACrm CcNATtlm CE am, THE POUOWIN0: '1 CERrWf THAT IN THE PEIIPORMANCE OF THE WORK FOR WMCN THS PE/MT Is M=W.1 SHALL EMPLOY PERSONS SUBJECT TO Aq'O COW1S=ATMN LAWS OF CAUPOITMA.' THE AIR T CALL 24 HOURS W ADVANCE FOIL ALL REOLNt1A ORSPSCTIONS AT ROS)464 saL COMvLEM DRAW=AT LOWZR AF*A FT=V=D. / PWT RAN Www M Nadel seek 'tl 1. NAMES OF frF=TB OR ROADS REA EW TO OR SOWNOSNO TILE PROPERTY. 4. LOCATION OF MMM 92WACl3 DSMOAL Ova M OR POIOPO6E0 2. OUrUXE G THE FIIOPEIRY.OMNO D6MENSIONS AND NORTH ONECTIOM EXPANOMN OF CMAOE DIVOM OVIIrv=. 3. dMINSIONED OUTLINE@ AND LOCATION OF ALL 610STpp AND R10tOam 6. LOCATION OF WEILD wrne I PAC=OF ONE Huwo=o FIFTY FT.' STIQRCTIDEs.ONCwtom COVETED AREAS SUCH AS PATIOS.OWWWAvs.AND WAIXs. ON THE P OPERTrY OR ADJOIPMO PROPERTY. _ _ :................ .. .. . . .. .. ..:. .........y............ ............. . ................. : MAP ON BACK } ......:.................... ..................... .......... ................................. ............................ DOPARMOff 1184 OtCLY Ar. 6 Oa. D.RnniMn M....Ibn Det. 11� 2�4- 3 -- _�.� - 9 7�Cr 2l zz ACGOUNTWO ONLY: AID/ FAG Pf CODIM FEE gam AMOUNT REMTTED CHICROICASH RECEIVED sv DATE PEISYOT/s0lVicf REQUEST NVACC R Invo E Z D/O`l5z 'd WOZ1--j HV0E:9 966L—SZ-6