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ruov41,1G-t< <br />CV <br /> <br />Applloottlon Acoopted Ely <br />Grout InopectIon fly <br />Onotruction InepoctIon Fly <br />II Commoola: <br />AIDE FACE ACCOUNTING ONLY; <br />Delo 3 -9-9 A... 07 <br />571 161 c,„„„ InorwetIon By Date <br />Dote <br />5 / sikelf <br />1/1111FLT-Ciedirl <br />PE CODES FEE INFO AMOUNT REMITTED alto ARII nrcrivrn BY DATE PERIVIIT/SIMVICE nsouElIT NUMBER INVOICE <br />35U1 7c, --- n - c -99 <br />t <br />--, , <br />iR 0 l)-1`A. b c-1 g <br />APII i ION !WI WU! III'UMP PEI <br />SAN JOAOIIIN COUNTY PIIRLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388, 304 EAST WEBER AVENUE, SIMKTON, CA 95201-388 <br />I7119) 46113420 <br />NOPIREFUNDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Cnmplide In TrillHems) <br />COUNTY FOR A PERMIT 10 CONCTIVIC / AND/On II/SIMI THE WORK DESCRIFIED. THIS AMICATION 16 MADE IN COMPLIANCE WITH SAT <br />115,3 AND 111F STANDARDS or RAN .10/101111,1 COI /WY minim: HEALTH SERVICES, ENVMONMENTAL HEALTH DIVISION. <br />OWNER'S NAME <br />CONTRACTOR <br />SUP CONTRACTOR <br /> <br />APUtlr RR / ifiAL".. qrS76- ps40 <br /> <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9 -1 <br />JOB ADDRESS/OR AMIE /3 7 r <br />1Ze -CfA hl,t1 eft 6i/a/W ILL/ °1644-i nuoNE K7S4 "7 --- 4 V.-T—i3f -74-d OR, 7 7J 77 /1 <br />X7- CO 6/10(4st tie) in Aonnrs0//7476///v-21,, Lfc, /I 7 Y.2.2. PHONES <br />fic CITY illariz _Cac P7EL SIZE/AMU <br />NEW WELL <br />INSTALLATION <br />0 Now 0 Elnoolr <br />REPLACEMENT wilt <br />0 WELL SYSTEM nrrAin <br />H P. <br />l>1.,M0NI1oniNn Wit I it 141 <br />0 rnonq CONNECT REPAIR <br />or rill NINE' SET FT. <br />0 OTHER <br />%/Anon EXTRACTION WELLS <br />rum WATER LEVEL <br />SOIL BORING <br />TYPE OF WELL/PUMP: <br />/TYPE or numn1 <br />ouT-or-srrnAcr WTI I_ 0 ororuystcAl Will 1/ <br />0 DESTRUCTION: <br />INTENDED USE .11-...., TYPE OF WELL coNfirnifeiioii SPECOICATIONS --- A <br />INDUSTRIAL 0 OPEN ROTTOM M u A. Or WEI I rxrAvAnN DIA. or CONDUCTOR CASING ----.....‘ 0 <br />DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE <br />PUBLIC/MUNICIPAL 0 nnivrri <br />TYPE or CARIWI/STFEI/T'VC 2 4' n'L.- 1.../ DIA, OF WELL CASINO 2 " <br />orr-DI Or onouT SFAI -"..- / 't ej ° ' 1-1 e f - SPECIFICATION Er <br />IRRIGATION/AG 0 OTHER GROUT RFAI INSTAI I Fr) RY Di,' Ile ," GROUT BRAND NAME E <br />iii MONITORING <br />APPROX DEPTH 1 <br />nnnut RFAI PlIEEPED• AV. ON.. . CONCRETE PEDESTAL BY DRILLER: El Yee ON.. s <br />. 6-0 {C .41: BCS <br />S <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AN!) 1 ' 111F Wow wn I RE DONE IN ACCORDANCE MTH RAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OE THE SAN JOAQUIN COUNTY, HOME OWNER OR LIT, rInFn ACKEIT RICINA 1 um CERTIFIER THE FOLLOWING' 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL NOT rmricre PERSONS SURJECT TO WORKMAN'S COPAPENRAT1ON INNS or CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: ' I CERTIFY THAT IN THE PERrOFIFEAW1F Or TIIE WrIRK ron %WIC!, THIS PERMIT is ISSUED. I EMAIL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' THE APPIIC O 1E4 ADVANOT. 1t,11 Al I ItI lt P#uTO II, 414.0 110 1. 5 *1 13001 4511-11123. CREAN ETK nnAwiNo AT LOWER AREA PROVIDED. <br />Slortod X T I ile(27747/7--C- <br />I (II-KIWI CIIERTER ROX/SlovE PIPE e I/ t0x; 6 1-°( V /1 7 e4 f <br />PROPOSED CONSTRUCTION/DRILUNG METHOD. MUD ROT Any ____ AIR ROTARY AUGER CARLE OTHER <br />PLOT PLAN 10tow In Fool.) Foals_ ' to <br />I NAMES OF STREETS OR ROADS NEAREST TO on ROUNDING THE PROPERTY. <br />2 OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />3 DIMENSIONED OUTLINES AND LOCATION OF All EXISTING Arlo PROPOSED <br />STRUCTURES, INCLUDING covEnEo AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS <br />4 LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />DEPARTNIENT USE ONLY