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• T SAN OAQUIN PUBLIC LIC HEALTH RSERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 95zb x <br /> JUN 0 5 199�. 304 EAST WEBER AVENUE, STOCKTON, CA <br /> ao9) aesaazo 3rd Floor <br /> ENVIRONMENTAL HEALTH NON REFUND►BlE VFNMR <br /> PERMIT/SERVICES -I M <br /> A CATON m HERE RY MADE TO THE SAN J AOIRN COINER'MR A PERMT TO CON6TRUCT AND/OR M6TALL THE WORK MMR,,EO.THIS APP[JCATON IS MADE IN COMPLIANCE WRH H.A <br /> JOAOWN COUNTY DEVELOPMENT TR1(,CHAPFER 9-1116.3 ANO THE BTANDARDs OF BAN MAOUIN CDII•IfY Fl1eL1C HEALTH eERNCES.ETORIIDNMEMAL HEALTH pNMDN, <br /> l✓rZ5' z'Ss$-Soo -oS _kr Zq z36"3oc-c�`1 �. <br /> Ae ADORESSIOR AmI (Ar6Z Z 3 -3D0'Y z 6/1�nGA�c�cr L{)"/✓d. em CA PARCEL BI/ASNF <br /> r 95 BABr lD <br /> OWNER's NAAEF CT, G(L.ISWe-D A Iry TRAwf, cA . 5 95376 3Z 7000 <br /> � / /,1 •� '/ lov PaFf Sr• ,iow r"*& <br /> COHTUICTOA_IYCOMAtfLL>< (.0.�5+.TAF•rS I Hrr,: HOMY- yaV +�±+t"'� AOOFEee�g iar;v. GA 94/Il GC• PHONIE MI •y OO <br /> 47 iovIS,['sr. <br /> p <br /> eve CONTMCTOR__{ QY_GS O✓ SAMPL,m& I ML. .corE" SAW. I&AFAHt; CA 9N901 I" PHow *$)Ysb,4 7 <br /> TYPE OF wvy yw,M ❑ HEW WELL ❑ RERACEAFEM WELL ❑ MOMROIEIO WELL/ ❑ OTHER <br /> ❑ MBTALLATON ❑ WELL oYBTFTA REPAIR ❑ oO9e-coNNECr REPAM ❑ VAPOR EXTMCTON WELL/ <br /> ❑N. ❑Rc H.P. DEPTH PDMr SET_FT. FIRST WATER LEVEL I <br /> TYPE OF Ft1w <br /> ❑ OVT M-BCRI/CE WELL ❑ OCOPHYMCAL WELL/ 1CF WIL eOWNO � IQ�4T 1�✓tII f <br /> ❑OEBTP11CT10N: <br /> INTENDED WE TYPE OF IN COIMTRUCTON SPECAiCATONA f <br /> ❑ NOUBTWAL ❑OPEN COTTON CIA OF WELL E%CAVATON CIA.OF CONLIIICTOR CASINO L <br /> ❑ DOMESTICNWVATE ❑GRAVEL PALTVBDE TYPE OF:AsINO/6TEELFIT CIA.OF WELL CAIPHO I <br /> ❑ PUBiH:/A,LMICIPAI ❑DRIAN DETTI OF OPK)m SEAL ePE[EICATON A <br /> ❑ IIOEGATION/AO ❑OTHER GROUT BFAL eiBTAlIfD eY GROUT BRAND NAME f <br /> ❑ MOHTTOmNO GROUT SEAL PIIMPFIF ❑Y— ❑N. ❑N. S <br /> i <br /> � D9TH I Ui bn cl LOCRNIG CIERTFR W OBTOVE PIPE <br /> s <br /> PROlOem CONJTIIICTON/DFCAINU METHOD: MUD ROTARY AM ROFARY AII0ER CABLE DIItA_Lr �$l{ <br /> I HFAEBY CERTKY THAT I HAVE PREPARED THIS Z;6CATION AND THAT THE WORK.`ALL M DOH,W ACCORDANCE WTH BAN AAOIAN COIMTV DIOMANCEB,STATE LAW6,AND RME9 AN <br /> RIXI ATONS OF THE SAN AAOVM C9I/NTY. HOME OWNER OR LICENSED AGENTT BONATUIE CERTIFIES THE POLLOWMO:T CERTIFY THAT M TIRE FERNORMANCE OF THE WORE TOR wHIC <br /> TMs PERMR IB ISSUED.1 SHALL NOT EMPLOY PER®NB BUeIEGT TO WORO„AR•e cOMPBMAl10N UVA OF CAIFW VSA' COMMCTOWB MRtlNO OR Bl16COHTMCi1N0 BONAl111E CEMIFlF <br /> THE FOLiDWINO: '1 CERTIFY THAT M THE PE)EOIWAMCF OF THE w W MR w "TMB•OOAR M IOUED,1 WRLL ENHR Y PERWNB tU6lECT TO MORgHAN•B COM•61AATION LAWS C <br /> C.WMWR ' TIRE AP•ULART NRAT CALL'AI HOLM6 IN ADVANCE MR ALL REU,AR®MIPSCTNHA AT LtA1 AAetiAII. COMRETE ORAWINO AT LOWER AAEA•RFOVRIED. <br /> "—i X TR4 <br /> On. <br /> Plot PLAN mrPr o-6A.I.1 A..I. � 'I 'm i <br /> 1. NAMFA OF eTR@TB on ROAoe NEAPEST TO OR 90 N THE PMFERTY. A. MCATON OF HOUSE SEWAGE IAIWOBAL WffrEM OR RIOMM <br /> 2. OUTURE OF THE PROPERTY,OIVNO OIMEHMONe AND NORTH OIRECTON, EXPAN CIN OF SEWAGE OIePUAAL evaTEM8. <br /> ]. mWNSIONED OVFFINFI N0 LDCATION OF ALL E%MHW AND PlbtOgy S. LOCATFTN OF WENS LMTIRN MLMUe OF ONE HUNp FIFTY FT. <br /> STRIICTUPE6,RA=?DING COVERED AREAS 61CH M PATOe,DRMWAYB.AFO WA . ON THE PROPERTY on AD.OIMW PROPERTY. <br /> MAP ON BACK <br /> v&AATMENT IME ONLY <br /> APplb..lew Aee.Pmd eT 0.H ��'� I(� L n,� &2 U <br /> GRFn I�11.n er D.1. Pvnp 6�wN.n h D.c. <br /> OwtrwBPn I:RP.PII�BY <br /> C.....- 3 8B YIi !'yu/ LfJ �f.fLG- <br /> IICCDIINTINO ONLY: AIDE FAU <br /> IRE coon FEE INFO AMOUNT RH.RTTED CIEt:"m"N R E,WD eY OAR PBB,NTIABINtE AIEOLRIT NI w INVOICE <br /> 20 <br /> O <br /> a woaa wv�� ei a66i-ez-s <br />