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A: PLICATiOU r0fi WU-ljrUMp PEU11T <br />SAN JOAQUIN COUNTY PUBLIC )IEALTII SERVICc S <br />ERVIRORMENTAL ITEXTiI OIVISIOU' <br />P 0 ny:P.1 44B IN SAl) J611Qtllu 6r T& n <br />S CCSTOii CA -$201X' <br />(2071 4.583420 <br />ROR.T"IlAOI[ I!IWIT WIM T TJAt FROM BATT ISSUED <br />IG+rw Vea y T rbJ<me W <br />Application (a here by wdo to the San io"in 6o,nty for ■ poi -pit to eornrruet and/or introit the cork descrtbad. Thla aMileatim is <br />:hada in-co¢pllsr,c'e with San Jo6quir, Ca.rtty Dayelopaent Tither Chapter 9-11 5,.�- yftl-djtfro SCardares of San Joarcpiirl Canty Public Msalth <br />Smlcot, ErTv(rormsntal Xaalth sion-/ --)-�e+ L(, l h%- L yl <br />• 1 <br />Job AddNw/or AP4# city TCd Parcol 51z�lAPNM ±0.5 <br />1 <br />.(WfWrrl La�e'650 �lt �J. Adders% ncrPbrsie ! <br />Contrsctor; Parc CtrP Address Old LICIT 605350 ph. 916)723-1776 <br />I <br />suf ContraGter V+1St H12Mt Et lliM AWrtss L1`0 5541375157 Phi r (916)QQ= 6 <br />TYPE !M [] WfW MLL ❑ Km4trxENr trlL ❑ "ITCAIlr L.iL a- _ ❑ CTM <br />IX DOTRUC11OW ❑ CM-01-VOYICE YELL (Ia"HYSILAL VfLL / ❑ SOIL 80AIkG <br />❑ (NSTAUATiON ❑ WELL STSTCM REPAIR 0 CR01S•CM11ECT•REPMA 11 VAPOR•EXTRAtTI011 Vf_LL I <br />171 Mew D A",, a.P, DfPITH PtrP IfT FT- Flllij WATER LEVEL <br />(TT►E DP Pt I VIM CwC.It 4-11S <br />IMM ED Vi 't ly'pf 9 tt cDJ24T��LDp =ff4ALc�aMi <br />❑ lYDtM11AL ❑ CPEH SOTTCH DIA. Of WELL EXCAVATIOM DIA. OF COl=6QR w1r6 _ <br />❑ OdrtSTiSIPAM.TE ❑ GRAVEL PACY/SiM TTPE OF CAStWMEL/PVC DIA. DF WELL GEII(0'�__ <br />U P[rDLICJF1xBMPAL ❑ UIVU R7TH Of U=T YEAR SFECUMATI&f �Q <br />Cl it.aiGlT1U1/AL n dim MOV SEAL IKSTALUID BT I=1 UA40 xAkE�..,_..._ <br />❑ NONITOR�NO "MT SEAL M"EDI 0 Tee i) Yo CCWCtETE PEDESTAL DT DRILLER: iI Tes'.11 A0 <br />A14ROX. b0 w LOUINC CHESTER DOX/SIO'JE PIPE <br />"Gro"O Gd tiSiltllcTkl RlDtt1LLW lkTH00: KM ROtMy AiR AOT)Ay AUrAA CULE OTHER <br />i <br />Ineraby cartlfy that .l haemo r4 -K •w•e4 Tx amliurlon snd that the work u ll be n eccorduncs with San Joaquin CwrlyOrdHruixn, <br />Stat- LWcj anKnave <br />d Au and AequIaIIor& of the Son Jaaquln County. owcr Dr Ilcrnsw myentit ai"ttro omrtifies the lollorirq: ■1 <br />certify•t�t in the rerfet 6.4. of the walk far Ihleh We permit is lsauad, I shall not top(oy Parsons sub)tct to uWKWei CpMP04ATION <br />leve of Collfornia." Contractor's hirirq or .ab-eo.,troetfrp oignrrura eertlflet the fallowing, • t eartlfy that In tha•parto manee <br />of The worl,d•for vh(cit MIA parslt (a.itvAd. I t:hatl O-P(ay ParsonsM <br />=ort to UORLSIA Ir. CCWFNSATION lawn of CaLlfornla.w TX(AH'{D:AIT <br />MM CULL tlO 19' DY F INUOMO C19MTWM9 AT i209) 4=1417. Cacplete dr tilrty t Lever mete prerided. <br />710nod XTitle r f pate? /J7� <br />1 <br />I PLOT K.M (Drew to Scall) 4cllo ' to <br />1. yai <br />aes df streets or road& near"T to or botrdlnp the proparty. 4. Location of hwne sawtgo dlspD"t systta or <br />2. ouzllna of the property, Diving Ciwvssiorn and NerLh dlrectIon. Pvopeaed a PftrinloA.of seimbpt dirpaeal systd.t. <br />S. 1119traloned outLtnM M4 location of Bit omitting and proposed 5. LDcatlon of walls within radius of .150 ft. an <br />strvotvrss, including covered k� sucn u patloe, dr(vcv&ya, the property or adjoining proparzy. <br />" kaie&. <br />✓%M DEPAXIMMT USE ONLY <br />APPI (Cot Ian Aeenoted ay • /" ` - L?l B&Ta -.)3 <br />Grout Irnpeet ion Ay pate �j PLry lnapocrton Dy _ Bate <br />Dastructlon impaction 4y D&ts- - 23 r Co-vrants: <br />Actau Tt a amn- Alb -9 FACS /H%C) ) `r <br />PE CDOET FEE fATO A1tODKT AEISTTID [SIfUMAMI EJ!C YEn DY DATE > PRkt7lMvYMl v fiT (YYDICf <br />>.`c -- ►5 15 l''1 � '1S n CDC41_ <br />TOTAL P.01 <br />