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MMISAN JOAOUIN COUNTY PUBLIC HEA�A. S ENVIRONMENTAL HEALTH DI 304 EAST WEBER AVENLIt CA 95201388 (208) 4893420 NON-BFEUNDABLE PEW I� -1 I 1 /.PPLICATION IS HERE I MADE TO THE SMI JOAQUIN COUNTY FOR A PERMIT TO CONRNICT ANOgR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SA .IOADUIN COUIY OEVEIOfMEENNr TTrLL`CHAPTER 9.111115..3 AND THE STAuDD.A-�ws OFF uw joAam COUNQT-y Pun IC H-EEAA"L�TH^SNMCm FNv bDHMEHTK HEALTH U,UPOH. JOB ADDRESSIOR'A^PW 2(�(0^T(oL� \0 e--> �V�{y/J�I.�Jtvf)I � J11 L-IC�} CRY J cy--'m I PAIcn SOPA OWNEWBNAMEN`5. 1��I��LL\\,.-T"�(('ILIA. .�InQLJ � C ,1,(t3:AQ ADOI�,.P(>f.,.'fac�-XS�� }�yt.�� A 06(0103,ww gib CONTRACTOR V k uj y1 �1\\T YA ADDlMft QXSI,L6 V l2il,, •L 1=2222-0±PHONE.. < BUR CONTRACTOR ' ADORESS VCE PHONE J TYPE OF WELL/PUMP ❑ NEW WELL ❑ PFPIACEMENT WELL ❑ MONRONNO WELL I ❑ OTHER ❑ NSrA TION ❑ WELL SYSTEM REPAIR ❑ OIGSBCONNECT wAHI ❑ VAPOR EXTRACTION WELL E ON o Rwlr M.P. DEPTH PrNIPSETFT. FIST WATER LEVEL I (TYPE OF MMPI ❑ ❑ O[ORNYMCJV.WEl1E ❑ SOIL BORVJO P DESTRUCTION: INTENDED UTE TYPE OF WLSL CONSTRUCTION SPECEICATAN{ ❑ INDUSTRIAL ❑OPER SOTTOM DU.OF WELL EXCAVATION DIA.OF CONDUCTOR CASMO D ❑ OOWSTICROVATE 13 GRAVEL PACKMIZE TYPE OF CAMNOISTEEUfPVC DLL OF WELL CARN0 ❑ PUSLKIMLMORPK ❑DRIVEN DEPTH OF GROUT SEK SPECIFICATION P ❑ IMGATIORf" ❑OTHER GROUT SEAL INRfAUM)BY GROUT SRAND NAME ❑ MONRONNG GIDIR SEK PUMPED: ❑V_ ❑Ha CONCRETE FEOETTK BY d6l1ER❑v_ ❑Ne s APITVTL DEFT" MDCXING CHESTER SOX %,f PIPE _ S R POSED CONSTLUCRONIONVINO METHOD: MND ROTARY AIR ROTARY AWED GABLE OTHER I HE+•EBY CERTIFY THAT)HAVE PREPARED TMS APPLICATION AND THAT THE WON,WILL M GONE M ACCORDANCE WRIT 9AN JOAtMN GOUTY ORDINANCES.STATE UW6,ANO MUS ANI REGDUTIONI OF THE SAN JOAOUINI COMITY. HOME OWNER OR VCENSRD AGENT'S SIGNATURE CERTIRES THE POtLOWRO:T CETRNFY THAT W THE PDEORMANCE OF THE WONT POR DUNK; TMI6 PEIMR IB ISSUED,1(HALL NOT EMROY PEASOM SVGIFRTO WDIR'MAlff CDMPBIYTON UWS OF CALFORMA." CONTPACMO M M M SMLON XL WO MMATLRE CERTPIEI THE FOLLOWING: '1 CERTIFY THAT M THE FEPIPD NCE Of THE WOIR FOR WMCH THIS POMR IS NSUED,I SHALL EMPLOY PERSONS Ip/61ECr TO WOAp1NUS'S CWNNSATIOM LAWS O' CALIFORMA,' THE ARP{ICAM MUST CALL 7 INDIA'M ADVANCE FOR AL1 RZOUIRSD INN Ift AT CZ04" iEa. COMPLETE DRAWING AT LOWER AREA PROVIDED. ebr�e SN�7�a Yi�.�I TIIN -T J\o JT i RDT RAM Draw b ibWl BaPla 'D 1. NAMOF STEE'ff OR ROADS WREST TO OR S011NDIFRR THE RNOPBRY. A. LOCATION OF HOUSE WMIAGE DNPOSAL SYSTEM OR PROPOSED Z. OUTLNE OF THE PROPFJRY,OIVINO DSIENBIONB AND NORTH DIIECTIOK EXPANSION OF SEVAOE DISPOSAL EYSfEMB. 1. DIMENSIONED 13 rt,i AND LOCATION Of ALL FASTING AND REPOSED S. LDCATION OF WELLS WITHIN RADIUS OF ONE HUNOIED NFTY FT. STRUCTURES,INCLUDING COVERED MFRS SUCH AS PATIOS.ONVEWAYS,AND WARS. ON THE PROPERTY OR AOJOMDIG RDPERrY. . MAP . . ".... DEPARTMENT WE OWT APPIM.Ibr Aawprad RI D.1. /,—�7—4 7 M_ Y"� Orau[IrapaNM B1 Dara Pv �IT DMa D_N lwr%Inp.90.BT G *y lo- ACCOUNTINO ONLY: AIDE FAC, PE CODES FEE INFO AMOUNT R[MRTED CHECKACAW RECH ISP DATE PERIAITItNMCE REOU6T RUAI91 INVOICE Z -d WOad Wd8Z'Z L66l-LZ-�Jl