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SAH JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9MI388 <br /> I2119) 46944N <br /> NON-REM13ABLE PERMR <br /> APPLICATION M HEIVE BY&"M TO THE SAN JOAOI M COUNTY FOR A PERMIT TO CONBTN[JCT AP4DIOR StSTALJ TME WOW DESCMBEO.THIS APPUC'ATON IS MADE W C0MPLJANCE WTTM SAN <br /> JOAQUlJ COl1NTV pEYR.OPIMEJR TTfl,,E,jC�HAPTER B-1116.3 AND THEA`FTMAADO OF aJW JOAOVMOUN <br /> CyTY MYKJJCM BC <br /> +HEALT "CES,q"N%DIM.IENT Al HEKTH DMS40N. <br /> JOE ADOREBipR AR., 7 L <br /> I . C �Ci V j V 1'✓G11( CfTY S I c c h I c PAJ�CEL S1ZElAFTI, <br /> oW1aElra wwEkacl"a I1 01 k VIlGVl ADowEas -7 0 E, C v I'/'a V S)(4 h PF•oNE s H 6 7 -0 30 S <br /> colrRACTORvaNC tc� :,0 �hUiyC:1'✓I°K�q� ADDIEEa 1403 '�. M4v�GI <br /> +2L <br /> stJ6 CONTRACTOR ADOFtF UC/ P)IONE• <br /> TYPE OF W'EtLRJMP: ❑ NEW Wftl Cl REPLACEmelfT Wa-L ❑ ►eOMTOANO WELL• ❑ OTHETt <br /> ❑ MSTALLATION ❑ W8L FYETEJA RFPAA ❑ CRom-r_ µFCT IIEPAM ❑ VAAOR EXTRACTK/H WELL, <br /> ❑H..,❑P-..* H.P, DEPTM PUMP EET FT. RRFT WATER LEVEL O <br /> TTYFf OF PVL <br /> Cl OUT-0FCERV1Ct WELL ❑ OfOfM'11CAL WELL/ I� SO.L SO RENO - B <br /> ❑DE6TRUCTiON� <br /> LKTFTDffD U•; TY"OF WELL CONI TICJCT;ah SPECIRCA /I A <br /> ❑ WOUST)YAL ❑OPEN BOTTOM 011k.OF WEU EXCAVATION DIA.OF CONDUCTOR CASINO D <br /> Cl DO).ESTICJPFVVATE ❑GRAVEL PAC ANNE TYPE OF CASI.)OISTEELAPVC DIA,OF WELL CASING D <br /> ❑ RJDuc Af)"tcwAL ❑DMVEH DMTIt OF GROUT BEAL �- 1✓ - SPfCIACATPON }_ R <br /> ❑ tFIFFGATIONIAQ ER O <br /> ❑OTHGROUT SEAL WSTAOM <br /> UT BY OUT GRANA) <br /> D N .IE_f6 <br /> 7 ( Id N ZW1•I{,T E <br /> L+IOWTORJNO D ED;GROUT SEAL RAMP ❑Y. qN. CONCRETE PMC47AL SY DRILLER❑Yr. ISN. S <br /> A"%ox.OBTIi j LOCKWO CHEtTtR BOXMTOVE PEPS `�- 1 S <br /> MOPOSED COMSTAUCTTOR/MLUNO PAM400: L/LPP ROTARY AIR ROTARY AUGER GABLE CTI- V M G l �U 5 <br /> 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THW APPOCATION ANO THAT TME WORK WILL BE DONE W ACCOPOANCE WITH BAN JOAoLRN COLWTY ORDHAHCES.STATE LAWS.AND IkAEf AHO <br /> RKIULATIOHB OF THE BAs JOAoIAN covNTY. HOME O'W`AR OR tJCtk"D AOZST Si ATVPW C2'RTIF4ES THE FOLLOWMG:'1 CEKrFFY THAT W THE PSWOf"ANCE OF THE W'01K FOR V,-," <br /> TMLS PERMIT IS ISSUED.I SSUILL NOT ELtPLOY PERSONS SLISJLCT TO WOMUJLAWS CO"WOMATION LAWS OF CALIFORJ{A.' COWTft CTOR'S 4UWM OR SLJE CONTRACTRIG MkATU E C* T FmS <br /> THE FOLLOWWAO: •I CERTriY THAT IN THE PCRFO—ATscE OF THE WOPK FOR W,*CH TFYa PE7VRT IS LmjEO,I SMALL EMPLOY PE1tSONS SUBJECT TO WOR►M"S COMPattATON LAWS DF <br /> C-AU`O`RN•t• THE AJ7UCAMT MUTT CALL 24 NOUtS W ADVANCE FOR ALL PtFOUnFD IMi2CT10JN AT RW)40WAW23. COMPLER DPIA"00 AT LOWER AREA PROVIDED. <br /> sipx_�� �1'I�c��-I TId. S�nr'c;- SIuFf 6 c7 <br /> KOT IUM{D—I.S.-;.3 S.-" to <br /> 1. NAMES OF ETTIMS OR ROADS NEAREFT To OR BDUNaWO THE PROPERTY. 4. LOCATION Of HOUSE SEWAGE DISPOSAL SYFTEM 011 PROPOSED <br /> 2. OUTLJNE OF THE PRCFEM-Y,urVwm DIMENSIONS AND FJ PITH IXRECTIOIt EXPANSION OF SEWAGE DISPOSAL aYST06". <br /> 3. DIMET+IS.ONM OVTL[NEL AND LOCATION of ALL EXIS'PLG ANO PROPOSED S. LOCATION OF WELLA WTTH.N RADR/S OF ONE HUNDRED FIFTY FT.' <br /> STRUCTURE'S.THCUJDktCJ COVQIED AREAS SUCH AS PATIOS.DISVEWAYt,APA WALKS. ON THE PPOPW"OR ADJO""G PMOPEitTY. <br /> ........................ <br /> M P ON BACKA <br /> _._........... ........... .... ::{..... .... <br /> :... <br /> ...................................... <br /> DEPAllM T'J"ONLY <br /> APdletbn Aeo.plsd DY ON. vZ 7 7 - An. . <br /> G•..a M D.R. P—W k-P--4—ST No <br /> Igy D.t. <br /> C. ,I.: <br /> ACCOUMT110 ONLY: AID• FACS <br /> PE COD" FS(PFO AAWLWr RaRTTLD )CAW Pt[CErViD NY "TIE PBO.fTNBtVICE RSOUE7T NL^Ufft WVDIC[ <br />