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SAN JDADUIN COUNTY PUBLIC H"'.TH SERVICES <br /> ENVIRONMENTAL HEALTFu BION <br /> P.O.BOX 588,904 FAST WEBER AVENU TOCKTONR CA'V1Mi3B8 . <br /> 1 <br /> izD9�asa•3a�D <br /> VoiliFFUBDABLE PERMIT EIIPIAF1 I YEAR FROM BATE 133UE8 Y <br /> ICe1Rp4E5 hI TFiotkltEl <br /> APfti1CAT ION IS HEFE BY MAGE TO THE BAN JOAOUIN COUNTY FOR AMERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.T105 APPLICATION IS MAGE M COMPLIANCE W110 SAN <br /> JOAOUN COUMY 04VELOPMENT TITLE,CHAPTER 9-1115.3 ANO THIS ii0ANtOrAAD8 OOF--SSAAN JOAOUtN COUHtY R1aLR:HEALTH <br /> ,SEERVICE.EFMRONMENtAL HEALTH DMMO"- (J FSA-0 <br /> AI AOOREBBAR APII/ 745 MoRT'H os[A 711\F�_1_CIT% /y S�yT�0(_I /+VN PARCEL EI2FJAPNF '� r26-03 <br /> 1J <br /> OWNER'S NAME VV11UN V GE' AOORFsa 100 I'�`��1r Sy N10FlEf y�8-��� 11�1 <br /> CONERACtOR TPG K A.I fi i R ADORES@ <br /> PUICONTRACTOR BIDU-6 0 rFErTR 1� ADaEsa 't/05 A Y3 _UCP pr-FT�3o_PRIONE F t3 p <br /> _... <br /> TYPE OF WELL/PLIMF ❑NEW WELL ❑RM EPLACEMEWELL ❑MONRONNO WELL/ Y'OTHER 5.7:M V J4Ql�_SU I�T�1 <br /> ❑NST�AALLILATK/H CJ WELL SYSTEM REPAIR ❑CNOs&COHNECT REPAIR ❑VAPOR EXTRACTION WELL F J <br /> ❑tiw�LJ P-FN N.P. OEATN PUMP SFT_m FIRST WATER LEVEL. O <br /> - rt YPE Of PUMP11 <br /> -I❑OUTAF-S/RERVICy�E13WELL - �OFORlYE1CAL WELL/ ❑ •OR SORNO <br /> 1C <br /> (3DEST@TIOH: �- AINT A/ITE 6,UV1 _ <br /> NifHOEO USF. IOF WEIR - CONSTRUCTION EPEC1FICANONS A <br /> ❑WMVIFGAL ❑T--IIOPENSOROM GIA.OF WELLEXCAVATION LS ' ORA.OF COHg1CTOR CASOIO D <br /> ❑DOMESTICIP OVATE 0 GRAVEL PACKMZE TYPE Of CASW STFFIJ V EJ - GIA.OF WELL CASINO O <br /> ❑PVILICAluNnvAt F❑3,mrAm. " Dim"OF OROUT SEAL "IQ/ - SMCMATION A <br /> _ ❑RIWGATIDN/AO IROTMR OROUt SEAL*WALLED BY ME+G'$ ORM <br /> DUt SRANO HAE E <br /> Ed <br /> I$.MONI70RHq LJ GROUT WEAL PUMPED:❑Y. . CONCRETEPEDEITALBYt1RLLER'❑Yr �IN S <br /> A►PRa K.DEPTH H O taaKm CRE"ER ROXXTOVE PIPE S <br /> j PROPOS"CONSTRMnON/ORLUNO METHOD:MUD ROTARY AIR ROTARY AUGER CABLE OTHER V s <br /> i <br /> I NEWSY CERTIFY THAT 1 NAVE PIEPARCO TMS APPLICATION AND THAT THE WDFK WILL RE GONE N ACCORDANCE WITH SAN JOAOIAH COUNTY ORENNMICES.STATE LAWS,AND RULE AND <br /> REOIILATIONS OF THE IAN JOAO"COUNTY.HOME OWNER OR UCENSED AGENT'S WaNATUR�CERtIF$E1 THE FOLLOWNO:'I CERTWY THAT IN THE PERPOFIAAHCE OF TIIE WORK fOR WRICH <br /> TMS PETOAH Is IBBUEO.I MIALL NOT EMPLOY PERSONS SVSJECT TO WI/RKMAN-S COMPMIATION LAWS OF CAUFOP08A.'CONTIMCTOR'B FSISNO OR SUS,CONTRACTING SIGNATURE CERIFTE1 <br /> F THE FOLLOVVM! 'I CERFOY THAT IN PIE PERFORMANCE OF THE V/OW FOR WHICH TMS PERMIT IS ISSUED.114ALL EMPLOY PERSONS OUSJECT TO WORKAIAK'S COMPTNSAHON LAWS Of <br /> a CALIFORNIA." THE ANNCAN7 I~CA''{{SA HOW N ADVANCE FOR ALL MOLMtEO NSreenoxl AT 1"014084422•COMPLETE ORAVANCI AT 1.0041%MEA PROVgEO- <br /> .I,a,R_ t•r <br /> a' <br /> FLOP PLAN p.w a 1er.1 sa.I., .� -w <br /> 1.NAMES OF ITREETS OR ROADS NEAREST TO OR 90VNDMM TM PROPERTY. <br /> LOCATION OF HOUSE SEWAGE OUBPOSAt 6YSTFM OR PPgnDSEP <br /> 1.OUTLINE OF THE PROPENrY,Amom DFWNMONB ANO NORTH DWIECTKNI, EXPANSION OF SEWAGE DISPOSAL IYITEMB. <br /> ]-OIIAEH61OTl[O OVILNfS AND LOCATION Of ALL EXISTING ANO PFi 009M B-LOCATION OF WttLB VM-HM RQXUG OF ONE HVMMWD FIFTY FT. <br /> STRUCTURES.iNttUM40 COVERED AREAS SUCH AS PATIOS,ONVEWAYS.AND WALK&- ON THE PNOPERTY OR AD"INIMO PROPERTY. <br /> T- <br /> K .. pI,*4 T- <br /> G <br /> 5L p ` <br /> o D% Sot VtPae . <br /> RVeT <br /> Po 1 nrT <br /> Oft f,5vI) <br /> 4 <br /> SnFk4a <br /> Cf Lyi0SE7 ,ST, <br /> s... ..... ...,,.r.- .... :..... <br /> DEPARTMENT LIRE OKIr. <br /> F APf4.~A--td 0T DNA A w <br /> ck—`+Pae! ST a.l• P1 Irw-fl—By DRi <br /> pNIM1k11Fn WPacrbn BY pSr4 <br /> CMMIQ4F: .. <br /> ACCOUNTING ONt7: X10/ TA[I <br /> PI COD" Ft71NFO AMOUNT R1NIt1tD CRRCKOIC'/1E14 RECDVEO BY GATE ►DPST/IERVICE REOUEST KVAIM INVOPCE <br /> Pup.Health So" -Erlviro,173(3196) <br />