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1„..3— 1 997 2 = 25PM FROM <br />APPLICATION FOR WELLIPUNIP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P.O. BOX 388. 304 EAST WEBER AVENUE. STOCKTON, CA ..201-388 <br />{209) 46B-3420 <br />RCIN-REFWIDARLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />(Complete In Trinticatel <br />APPLICATION $R HELD me LIAO To TRE SAN JOAOUIN COUNTY FOR A PEARAIT TO CONSTRUCT Ai407.0R INSTALL THE %NOR( DESCRIBED T/08 APPLICATION IS MADE IN CO471 JANct v‘sTsi AN <br />J0401104 COUNTY DEVELOPMENT TITLE- CHAPTER 9.1 115,3 AND THE RTANIOAROS OF nAm joAotna, COUNTY 41.18UC HEALTH SEWCES. Er4v1Ror4UrNT Al HEALTH Ortn8sON <br />JOE AODRESS/OR APNII t•tfr1-42' 4"%d4h' AZE- 044e) ir -57,telv.72:fri1/4/ PARCEL 8174APNe <br /> Anonr_sg• 2.0 //4")i dupti,(4/W4 1"/ IR.oreE S 61 2%i $V857-(5) ri <br />CONTRACTOR 1/114—M.) D/2‘2-4/Aa? ADDRESS /1?0. /OX 2-1L/Cf72".° YPRO.4 .(C/6)7?)4-47/62)00 <br />PUN CONTRACTOR Annnc,s8 UC• PHC:Fvf, r <br />NEW evSLL <br />/NSTALLAT/ON <br />I=1 Nee. Ree.i. <br />TYPE 9F WELL/PUMP: XmON/TORINO WELL • 0 OTHER <br />13 CROSS-CONNECT REPAIR <br />DEPTH C•JPS ,' au TT. <br />0 DE,OPHYSrcAL WELL <br />00E-rnucT,0,, <br />vAPOR EXTRACTION wELL • <br />r/RsT WATER LEVEL <br />fl ROIL gompla <br />REPLACEMENT WEU_ <br />WELL SYSTEM REPAIR <br />ovr-of tiFnvvct vvELL <br />rrYPE OF PUMP; <br />/cef- <br />01/ <br />01A. OF CONOUCTOR c AsING <br />DI•. OF wELL CASINO <br />tr.r.ctsscATPON <br />/4(e-77,1-A11) GROUT BRAND NAME <br /> OTHER PC409GCED COMSTRUCTIONMOSILIPSO METHOD' MUD ROTARY AIR RDTRV AUGER <br />INT ENDEO USE <br />0 INDUSTRiAL <br />DO mESTIC/PRiVATE <br />PUBLICIMUNICIPAL <br />IRMO AT i074/AG <br />mot-RTC/LINO <br />APreio I_ EARTH <br />CONSTRUCTION FPECIFICATIONA <br />MA_ OF WELL EXCAVATION <br />TYPE Or CA RiterDsT EELAPvc 4d re" /VC , <br />DEPTH OF pRout PEAL <br />(motif DEAL RD/TAILED SY /lf eefe14/C___ <br />GROUT BEM Pi tufts', 0 ON. <br />LOCVNG CHESTER 11010ITTOvE PDT <br />CONCRETE PEDESTAL BY DRILLER: U y.. Ne <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />..)4GILAVEL PACK /RITE <br />1:1 DRIVEN <br />0 OTHER <br />C> —3 <br />I HEREBY cERTIFy THAT I HAVE E'REPARED THIN APPLICATrON ARO THAT THE wIONC 2.filL. RE DONE NJ ACCDROANot WITH RAN JoAOUDI COUNTY ORDINANCES, sT ATE I_Aws. ARO RULES ARO <br />REGULATIONS OF THE RAN JOAOOP/ COUNTY. HOME OWNER OR LICENREO AGENT'S BIG-NATURE CERTWIES THE FOIJECIVAMG! -r CERTIFY THAT IN THF pERfoRmApk:F or T,.r wow FOR WHICH THIN RERLUT IN ISGRIED, I SHALL NOT EIATICITY PERRONS EGJEIJECT TO 2/ORILNIANFF COmPERRIATTORI LAWS OF CALIFORNIA: CONTRACTOR'S HIFONO OR ER.171-COWTSIAC TING SIGNATURE CERTIFIER <br />Tut EoLLowwfs; I GEEtTiFy THAT IN THE PERFORMANCE Or THE WOW FOR WHICH TERF PERMIT Is inguED, I SHALL EMPLOY PERSONS SuRJECT TO WORKIVAI-P1 COINVENIIIITTON LARD; OF CALIFORNIA,' THE *P#9l14Y NIUFT 9IILL 24 1421.414 IN ADVANCE FOR AU. REWARD) pinewooNs AT mom AGO.11422- Cer•PLETE DRAWING AT LOWER AREA PRovIDEo. <br />7R:reed <br />P_ 1 <br />PLOT rum le tl../.1 Roof.. <br />7 . N AIWA' Of STREET9 OR ROADS NEAREST TO OR BOUNDING THE priortrrry. <br />OUTLINE Or THE PROPERTY, OPANO 131MENO7ONS AND MONTH Dry'etcnoN, <br />3_ <br /> <br />DIMENSIONED OtfTLINEB AND LOCATION OF ALL EXIsTwo ARID PROPTDDO <br />STRUCTURES_ SJCLUorNO COVERED AREAS SUCH All PATIOS. ORIVEwAYEI, ANL) WALES. <br />DEPARTMENT USE 0771-T <br />OmeT 00 Pump 14,..pacytar, ey <br />Acca..0e, Ae....r.4 Er <br />Grout Irmolc...." 51 <br />y <br />ACCOUNTING ONLY: I AID, FAC f <br />PE COOEI FEE INFO AMOUNT Rs14iyiEo CHECK, ICA 614 RIC VIVED ST 041 Fl E nenu‘s iNvoscE <br />5 3o , S l', -t;- 0 0 .3.'?, 9 <br />t AAA rcl <br />Dm. <br />Pub Health Serv. - Enviro. 173 (3/96) <br />CPA74ER'S NAME <br />4. locA3/014 Of ROvsE IFEWAGE EnnPonAi sysrcm on PROPOSED <br />EXPANFION OF SEWAGE 078POSA1, (SYSTEMS <br />U. LOCAT101, OF wrtin vanDt• RADIUS OF ONE NuNoreED FIFTY TT <br />ON THE PROPERTY OR ADJOINING ppopErirf <br />Date <br />Sir 3 /9 <br />Prt-t.ClEt-f <br /># of pages I <br />From <br />Post-it' Fax Note 7671 <br />co.toopC (...,9A1„/