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N JOAQUIN COUNTY PUBLIC HEALTH SERVY ENVIRONMENTAL HEALTH DIVISION P,O, BOX-%M 804 EAST WESER AVENUE:, STOCKTON, CA 95201388 (209) 4871_34211 YOM-REFUNDARLE_PERMrT APPLICATION IS HERE BY MAOI TO THE SAN JOAOUtN COUNTY FOR A PERMIT TO CONSTRUCT ANOJOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRTH r- JOAQVIN COUNTY O"LOPMZEHT TTTTF-CH�A{R'TER H-N1 1 15.3 AND rNEr GT.A.14DAAR�O9 OF SAN JOAQUIN COUNT`/PUBLIC HEALTH SERVICES,ENVM%ONMFN7A(,HEALTH DtV SIOQN. JOB AD,,"ssLOR AP-N/ Z 3✓ ty��,rAjEs7— /�'FI'Jrj S/ u--zE / CITY �I /"�yJ�//��yJR� (� /� �+ PARCEL SU-VAPNs,-u ( � S OWNER'S NAME.BRUK of gRy1CKJGA _ ADOPE98?000 R&14p—/1 URL &- -�c0 PHONE I CONTRACTOR UL.�1�2- .ZN`G T� ,,DOREs6] /f MA4J.boN Ale--&& Aw-, /J•••'G7/y R+�N�{€y.��G3'/-�.>3 6Ue CONTRACTOR Ui NGIC , Z �7�� J`Q'L 'S l S,a 9t/y 9,y�1/rT2n G!/ /(I SS—UC•7�S`��PHO E#� TPP{Of WRI'PVMD- ❑ NEW WELL ❑ nEPL.�CEMENT"'tu L: NIONTORMIO-'eu T ❑ OTT E ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ c7ios -CONNECT AEPAIR O VAPOR E)(TkkCTION WELL J ✓ ❑H.—Cl R.tp.f, H P. Df PTH PtMIP SET FT. FIRST WATIM LEVEL O (TYPE OF PVMPI �-; ❑ OVT-OF•S1C EhVf WEU LJ Omp"YS'CAL WELL J 9011.BORING S B ❑bESTRUCTION: INTEMFD Usk TYI6 OF WELL CONLTRUCTION Avt; ?%4CATIONI A ❑ Woua. OAL ❑OPEN SOTTOI./ DIA.OF WELL DtCAVATTON DIA.OF CONDUCTOR CASINO D ❑ DOMEBTIClPMVATE ❑GRAVEL PA[Xt=E TYPE OF CABINOrSTEEL'RVC-7 -yam DIA.OF WELL CASING D ❑ PVGUC, UUN')CIPAL �DWVEN DEPTH OF GROUT SEAL G(n��O �"`-l SPECFK-'ATICN ❑ IRRIGATION/AG ❑OTHER GROUT VEAL INSTALLED by rJIZJLL E'fL OAOUT OFLAHD NAMEp'LJIcw� ❑ "0wTOPo:JG GROUT &CAL PUMPED: ❑Y.. ❑N. CONCRaFTE PEDEUTAL SY DRILltil❑Y— ❑No S AYLTOX.VOITH O / L c / LOCXXNQ CHEWTER DOXtSTOVE PIPE S PAO►OStD CONS77LICTIONIMI-11"a k#Cr"OD: MVD ROTATY AIR ROTARY AUOEA CABLE OTHER I HE^£8Y CERTIFY THAT I HAVE PREPARED T}SP APOUCATtON AND THAT THE WOM WALL DE DONE IN ACCORDANCE WITH SAN,/CAQUIN COVNTY ORDINANCES.STATE LAWS.ANO RULES ANC REOUL ATIONS OF THE SAH JOAQUIN COUNTY, ROME OWNER OR UCENSED AOENY'S MONATURE CERTIFIES THE FOLLOWTNQ: -T CERTIFY THAT IN THE PFRfOAxAANCE OF THE WORK FOA WHICV THIS PEAMT Is ISSUED,I SHALL NOT EMPLOY PERSONS SVWECT TO WOPOWAM'S COMP04ZATION LAWS OF CALIFOMAA.- CONTRACTOR'S MRINO OR SUBCONTRACTING SIGLHATVRE CEKnFIEI THE FOLLOWING: 'I CERTIFY THAT IN THE I EAGOP MANCE OF THE WOPK FOR WHICH THIS P UMT tS ISSUED.I SHALL ELAPLOY PERSONS SVBJEC. TO WORKMAM's COMMNSATTON LAWS Of CAL110RNI T AP•gRCANT MUST CALL X24 HOUR*IN ADVANCE Fl"ALL RitllM16M IN"PVC11044 AT Ra+f 44MJA22. COMPLETE DRAWING AT LOWER AREA PROVIOED. Tt.I.��V/�?1?1l1)1/11iIz2j 7-7-- y Gl y o•t. —Z3 PLOT I'LAN IDruA.r t.sa.l.l So•i• t. I- NAMES OF LTRFETS OR ROADS NEAREST TO OR MOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PAOF'ENTY,GMNG DI164EN67ONS AND NORTH DLRECTRON. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINF.II AND LOCATION OF ALL FXr9nNG ANO PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. GTRVCTTIWS,INCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PADPVtTY OR ADJOIMNG PROPERTY. T77 ...... ....... MAP ON BACK ............ . ........ ......... . ........................................ PEPARCTMENT use ONLY Av.11..I1—Aov.ot.d By D.0 A— Weu1 Mr.eetbn Sy DN. P%—v ____A by b.l. 0•.Iluctlw�Mwv.otl.n Oy - D.I. ACCOILXMNG ONLY: AJDf FAC) R COD" FEE INFO AMOVNT RIIMFTTED CHECKSMASH RECBVW sY DATE v9PSITf&IDrlCF REOV£AT NLIMS6t INVOICE F,F,I I