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wrruow uvn r.n-M u4rYRIr rcnAU1 ` F -SAN JOAOUIN COUNTYTUBLiC HEALTH SERVICFA, 1 �mhvENVIRONMENTAL HEALTH OIOISION kJ 3D4 EAST WEBER AVEWF.STOCKTON;CAIt MM 1 (2091 4883420 31-91 F100r HOPFREFUNDARLE PERUrr _ p� APPLICATION WHERE pY MADE TO THE SAN JOAQUIN COUNTY FOR A PEIWR TO CONSTRICT ANDION NSTALL THE WORK DESCRIBED.TNS APPL.ICATON IS MAGE N COMPLIANCE WTT118AN JOADIIN COUNrY DEVELOPMENT TALE,C HA PTER 8-1115.3 AND THE STANDARDS OF SAN JOAGIAN COUNTY PUBLIC HEALTH`SEANCES.ENNRONMENfAL HEALTH DIVISION. JOB ADDRESSOR AFNl� O/ // GIC �4//e ��r 5 t/v �y j�OC'/l JOS/ PARCEL SIMAP IP 3 S'o Fu - �/%/Ra, Shy f� iza X44-1 yip OVMEArB NAME /�o//�/l CONTRACTOR Frli�,ln7iy/PA `f /�l SO�i�Ti o2a < aIp CONTRACTOR ADDRESS t� Jul4H LclC�s+3-�63�3�� PNONE S'4isSWSY-rtt"r7f '�. TYPE OF VNEWR/MP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MpMTORNOwELL! ❑ WSrA TON ❑ WELL SYSTEM REPAIR ❑ GOBBCONHECT REPAIR �❑ VAPOR EXTRACTION WELL J ❑NP.P❑NSW H.P. DEPTH RUM SET—Fr. ER6f WATER LEVEL D STYPE OF PUMP) - ❑ ovroFeEmncE WELL ❑ oenPHYpcALwELL r wa SONVlO "/15,Z(f 9 zZ� 3 `: e ❑OESTRIKTON: OL/=Si F e. INTENOM UAE TYPE OF WELL CONSTRUCTION SPECIRCATIONA A ❑ HNDIISTNAL ❑OPEN BOTTOM DU.OF WELL EXCAVATM DIA.OF CONDUCTOR CASINO D ❑ DOMEEHCIREVATE ❑ AOUStZF GRAVEL PTYPE OF CASINOISTEEINVC DIA,OF WELL CASINO D ❑ FVBIx:IMUNKIPAL 00MVEN DEPTH OF GROUT SEK SPECIFICATION R ❑ PWOATIONfA0 ❑OTHER GROUT SEAL RMAIIED SY OROUT BRAND NAME E ❑ uoNrtORHo GROUT WALPVMPED: ❑Y. ❑Ne CONCRETEPEDESrALB MUER:❑Y. ❑NP x , APmmai DEPTN LMTUNO CHEBrER SOJMTOVE PIPE - 5 PROPOSED COMBTAIICDDXlORLLIIN METHOD: MUD ROTARY AIR ROTARY JC AUGER CABLE OTHSF 1 HEREBY CERTIFY THAT 1 HAVE PIEPAT TMS APPLICATION AND THAT THE WORK WILL SE DONE N ACCOROANCE WITH SAIL MAOUN COUNTY OPDInAN U,STATE IAWE.ANO RUIEB AND REGULATIONS OF THE SAN JOADUIN COUNTY. HOME OWNER OR UCENSM AOENT'S MNATURE CFRDRES THE FOLLOWING:T CERTIFY THAT W THE PERFORMANCE OF THE WORK FOR WHICH THS PERMIT Ip ISSUED,I®BALL NOT EMPLOY PFASONB SUBJECT TO WOIDGAAMA COMPENSATION LAWS OF CAUFOMSA.' CONTRACTOR'S HIRING OR SUSCONTAACTNNO SIONANIE CERTNTE6 THE FOLLOWING: -1 CERTIFY THAT N THE PEEOAMAMCE OF THE Y POLI WHICH T11m MMR IS ISSUED,1 SHALL EMPLOY PERSONS SUILR=TO W VUUNAN'S COMPENSATION LAYS OF C.LUFOw Ty�E,APPUCANT MUSTC BIO WADVANCE TOR REQUIRED WSlg "ATOSq40*44=- COMPLETE ORAWNO AT LOWER AREA PRO"DED. erose x'__r_ ` TLD. S/6. Sr!r in 711 f o.. 2 /Zll�/ RAT PLAN IV.m Se WI MH 'm 1. NAMES OF STREETS OR ROADS NEAREST TO OR p UNDINO THE ROPFJRY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PNOPO$ED z OURSF OF THE PROPERTY,ONM DIMENBgNS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OURINF.B APO LOCATION OF ALL EXKTWO AND PROPOSED r; LOCATION OF WELLS WTTMN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES.NCLUDINC COVERED AREAS SUCH AS PATO$.DRVEWAYB.AND WALKS. ON THE PROPERTY OR ADJDIMM PROPERTY. L . ...... .. .- . MAP ON BACK ��E� ��NA� (EE�y/[�� DLTARTMElT ME OMIT 2- ;&6% ] PAYE AP 11 1u n Amgrc!ST � 6.1kW- -"� — Go. G- O•wl I,.Psl..,er wl.. Pvmo h�p.Om eT pn. p.lnc$m e+o Kbn Br w.. OPmmstt.: ;16%16 %0%6 tb' - gal f9fCk(WISk.k TQ 0,1:114 ACCOVRTIMO ONLY: MIDI FACT !� PE COD" FEE PNFO AM YUNTREArTTED emmu CASH PffCBVFD BY DATE PE MITSERNCE REQUEST XVAIEI INVOICE orA (4q� 2 1 t1 r d �1O'J� b�IdZ©'Z 8661-LZ-Z t