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• T <br /> SAN OAQUINPUBLIC LIC HEALTHIDIV �1,;VxkPUMP RSERVICES <br /> ENVIRONMENTAL HEALTH DIVISION 95zbx <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 /> APPLICATION m HERE RY MADE TO THE SAN J AOERN COINER'MR A PERMT TO CON6TRUCT AND/OR M6TALL THE YFOW MMR,,EO.THIS APP[JCATION 16 MADE IN COMPLIANCE vRTH H.A <br /> JOAOWN COUNTY DEVELOPMENT TR1(,CHAPFER&1116.3 ANO THE BTANDARD6 OF BAN MAOUIN CDII•IfY Fl1eL1C HEALTH eERNCES.ETORIIDNMEMAL HEALTH tMRMDN, <br /> l✓rZ5' z'Ss$-Soo -oS _kr Zq z36"3oc-c�`1 �. <br /> AB ADORESBIOR AmI (Ar6Z Z 3 -3D0'Y z 6/1�nGA�c�cr L{)"/✓d. em CA PARCEL BI/ASNF <br /> r95 BABr lD <br /> ONTJER's NAAEF CD G(L.ISWe-D A Iry TRAwf, cA . S957374 <br /> 3Z7010 <br /> � / /,1 •� '/ lov PaFf Sr• ,/DSF r"*& <br /> COHTUICTOA_IYCOMAtfLL>< (.oNS+�nOn•rS I Hrr,: HOMY- yaV +�±+t"'� AOOFEBS�g iar;v. GA 94/Il GC• PHONIE MI •y OO <br /> 47 LF✓IfiE 8r. <br /> p <br /> eve CONTMCTOR__{ QY_GS O✓ SAMPL,m& IML. .corE" SAA, I&AFAHhCA 9N901 LIC'/ PHow *$ Ysb,4 7 <br /> TYPE OF wvyyw,M ❑ HEW WELL ❑ RERACFAFEM WELL ❑ MOMIOHME WEEL/ ❑ OTFIEFI <br /> ❑ MBTALLATION ❑ WELL oYSTFTA REPAIR ❑ oIOea-coFl•IEcr REPAM ❑ VAPOR EXTRACTION WELL/ <br /> ❑N. ❑Rc H.P. DEPTH PDNA•SET_FT. FIRST WATER LEVEL I <br /> TYPE OF Ft1w <br /> ❑ OVT M-BCRI/CE WELL ❑ OCOPHYMCAL WELL/ 1CN WIL eOWNO � IQ�4T 1�✓tI/ f <br /> ❑OESTP11CT10N: <br /> INTENDED WE TYPE OF IN COIMTRUCTON SPECAiCATIONA f <br /> ❑ VIOUSTWAL ❑OPEN NOTTDN CIA-OF WELL EXCAVATION CIA.OF CONEIIICTOR CASINO L <br /> ❑ DOMESTICA'WVATE ❑GRAVEL PALTVBDE TYPE OF:AsINO/6TEELMT DIA.OF WEFL CAAFNG I <br /> ❑ PUBiH:/A,LMICIPAI ❑DRIAN DETTI OF OPK)m SEAL SPE[EICATION A <br /> ❑ IIouGATION/M ❑OTHER GROUT BFAL INSTALIfD eY GROUT BRAND NAME f <br /> ❑ MOHTTOWNOGROUT SEAL PUMPFp ❑Y— ❑N. CONCRETE PFMeTKrDNIEEII❑Y. Ow <br /> i <br /> � DLPTH I Ui bn cl LOC6NIG CIERTFR W USTOVE PIPE <br /> s <br /> PROlOSm CONST,IICTONIDNLIENU METHOD: MUD ROTARY AOI ROTARY AII0ER CABLE DIItA_Lr �$l{ <br /> I HFAEBY CERTKY THAT I HAVE PIEPAFED THIS A146CATION AND THAT THE WORK.`ALL M DOH,W ACCORDANCE YITH BAN AAOIAN COIMTV DIOMANCEB,STATE a;6.—AND RMEe AN <br /> RIXI ATIONS OF THE SAN AAOVM C9L/NTY. HOME ONTIER OR MI Ne AGENTT BNINATUIE CERTIFIES THE POLLOWMO:l CERTIFY THAT M Tl1E FERNORMANCE OF THE NOIR TOR wHIC <br /> TMs PERMR IB ISSUED.1 SHALL NOT EMPEIIY 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 PE1fOIWAMCF OF THF w W WR NMICN TMS•DOAK IS MM)ED,1 WRLL ENRAY PERWNB tU6lECT TO N'ORIDHAN•S COM•6MATION LAWS C <br /> C.WMWR ' TIE AP•ULAIFT MIAT CALL'AF HOLM6 IN ADVANCE POR ALL REU,AR®RNIPACTXHCS AT LtA1 AOiAII, I:OMPIETF ORAWINO AT LOWER AAEA•FFOVIDED. <br /> "—i X TH4 <br /> On. <br /> Plot PLAM mrF.v o-Sa.ml Se.N � 'I 'm i <br /> 1. NAMFA OF STRZtT8 on ROADS NEAPEST TO OR WINmNIG THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DIBPOBAL WffrEW OR RIOMM <br /> 2. OUTERIE OF THE P,OPERTY,OIVNO OIMEH6EONe AND NORTH DIRECTION, EXPAN CIN OF SEWAGE OIePUeAL SY>< 8. <br /> ]. mWNSIONFD OVFFINFI N0 LDCATNIN OF ALL E%M1NG AND Pmlml I S. LOCATFTN OF WFSLe LMTIRN MLMUS OF ONE HUNDRED FIFTY FT. <br /> STMICTUPE6,RANGING COVERED AREAS 61CH M PATRIS.DNVEWAYS.AHO WA . ON THE PROPERTY on AD.IOIMW PROPERTY. <br /> MAP ON BACK <br /> :.......i............c......:......o-.....:.....•6......: <br /> v&AATMENT IME ONLY <br /> AAp1I..TI.w Aee.Pmd eT 0.H ��'� L(� L n,� &2 U <br /> GRFn InN�p11.n er OO. Pvnp Ir�astl.n h D.c. <br /> Owt:wlbn I.RP.vII� <br /> By <br /> C.....- 3 8B YIi !'yu/ LfJ �f.fLG- <br /> AccoIINTINO ONLY: T-- <br /> IRE <br /> IRFI•F coon FEE INFO AMOUNT 1®.RTTtD CHEt:"m SN R ETVFD SY OAR PBRNTISBENtE"CLRIT NE w INVOICE <br /> 20 <br /> O <br /> a woaa wv�� ei a66i-ez-s <br />