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�LICACO N FOR PUBLIC HEA PERMIT 6� 1 <br /> (J� SAN � AQUIN COUNTY PUBLIC HEALTH SER �.cS E�SVE .0// 1 <br /> ENVIRONMENTAL HEALTH DIVISION /J <br /> &304 EAST WEBER AVENUE, STOCKTON, CA 95202 LWAI✓ -y <br /> �,�j�. �✓ 468-3420420 <br /> MOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OTE ISSUED <br /> ICompl/N In TrIpREA1eI <br /> AP'UCATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FORA PERMIT TO CONSTRUCT AND/OR INSTALL THE WORE DESCRIBED.THIS APPLICATION 19 MADE IN COMR,I AN <br /> JOAUOIN COUNTY DEVELOPMENT TRIS CHAPTER 5-1115.7 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DM N.pi <br /> JOB AO'DRE6OR ANI 6723 CY p��JJOYPARCEL SIZJAPN <br /> OWMERS NAME S•Jl PHONE <br /> /..�I.� <br /> F_ JEfCLIOi//L'N �C ] FHONEF ! -/v�'-�^�"_G•, <br /> CONTRACTORLC. J//{y ADDRESS Od S N[ f� p <br /> Ave CONTRACTORPD ru.nl bS'u-1%vwA-�-. A,•. SC_ 7___ <br /> �] Y ADDRESS .iG� na 4s�r7s LICJ -{L P110NE/(?09J�/b S-A>/, <br /> TYPE OF WEM4`UMP: ® NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER <br /> /I ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS ONNECT REPAIR ® VAPOR EXTRACTION WELL/ rE <br /> 414 ❑N.w❑R.P H.P. DEPTH PIMP GET-FT. FIRST WATER LEVEL O <br /> H VPE OF MMPI <br /> ❑ OUT-oA.m OE WELL ❑ GEOPHYSICAL WELL/ ❑ SOIL BORING S <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WEM CONSTRUCTION SPECIFICATION4 A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 6-(0 _ 'Y � M DIA.OF CONDUCTOR CASINO /if O <br /> ❑ DOMESTIONRIVATE ❑GRAVEL PACXJ90EPg TYPE OF CASINOBR /' C. <br /> TEEIVC / Sn-&( yD DIA.OF WELL CASINO _ L IY O <br /> ❑ PVBIICMUNICIPM ❑ORVEN DEPTH OF BMW SEAL ((ll 61 / SPECIFICATION <br /> q❑ NSSOATION/AG ,,/� �❑� OTHER GROUT SEAL INSTALLED BY'ILI'Oa Aa(� OROUT BRAND <br /> ycy MONITORING/e"iradkE GROUT SEAL PUMPED: ®Ys ON. CONCRETE PEDESTAL BY OPlLLE1t❑V. ON. S <br /> APMO%.DEPTH '?o LOCKING CHESTER 80X/STOVE PPE YES s <br /> PROPOSED CONSTRUCTIONN LUNG METHOD: MUD ROTARY AIR ROTARY AUGER_ CABLE OTHER <br /> I HEAEBY CERTIFY THAT I HAVE PREPARED THIS AP LIE-ATION MID THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OROINANCES,STATE LAWS.AND RULES AND <br /> ItEGULATIONS OF THE SAN JOAGUIN COUNTY. NOME OWNER O0.LKEN6ED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"1 CERTIFY THAT MTHE PRFORMAHCE OF THE WORK Mn MJNICH <br /> THIS PERMIT 19 ISSUED,I91HAU HOT EMPLOY PERSONS SUBJECT TO WORRAIAN'S COMPENSATION LAWS OF CALIFORNIA: CONTRACTOR'S HIRING OR SUS ONOIACTING SIONATIDE CERT.IRIS <br /> THE FOLLOWING: •I CERTIFY THAT U THE PERFORMANCE OF THE WORE FOR WHICH THIS PERMIT le ISSUED,I SHALL TAFLOY PERSONS SUBJECT TO WORIOMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.' THE A CCAHT MUST CALL 24 NOIEIS IN ADVANCE FOR ALL REQUIRED fff& / TIONS AT DHHH 41HJ42E. COMPLETE DRAWING AT LOWER AREA RIOVIOED. <br /> elerad X h�z� \�-++ � TUN, ��{�e /�/CJ 1(On lqA r. D.I. C-II y <br /> 0.0T MM Idnv Hs Be.I.I SSM. 'to <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE RIOPERTV, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On i3OIOSED <br /> E. OUTLINE OF THE PROPERTY,GIVING OWENWHS AND NORTH DIRECTION. EXPANSION OF SEWAOE DISPORM SYSTEMS. <br /> ]. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WRMN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALES. ON THE PROPERTY OR ADJOINING PROPPITY. <br /> DEPARTMENT USE ONLY �'/O/ <br /> APNe.11en Avveelad BY Wle G(r /y MY 6000 <br /> GmN 4wpeeeen BY O.le Rene M.oeHlen S1 Otle <br /> De.HncUm Irwneelbn BY pe,e <br /> C..: <br /> ACCOUNTING ONLY: Am/ FAC/ <br /> FE CGOFJ FEE INFO AMOUNT RBATTE) CNECX/UCASH RECBVEO■Y DATE REQUEST NUMEER INVOICE <br /> Ift <br /> ?v0.Health SON.-EnvirD.173(157) <br />