|
' (C—PM1E In TPiPllatd)
<br /> JOAQUIAPPLICATION IB PHIS!BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WON(DESCRIKO.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN
<br /> JOAOVIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11116/1,3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH MFVICEB,ENVIRONMENTAL HEALTH DIVISIONN..�
<br /> Joe ADDPEBBN�APNt C�r +2 �/1ELTN LSV CITI�I PARCELSQUAI'm /QL(p•J ''Z
<br /> OWNER'S NMI,I�I �U�I//,LI.�AIZ I/� �{�..� ADDRESS /j p- VMS M.,,JEQ (-.J R I y•�/�
<br /> CONTRACTOR. -ME I(1�I�l� ' fG��bFCZ1 SS ADDReB�d x L76�I I1 6 LACI /J3 D S •]!� ,I
<br /> :� VWVG^ fMONEF .J�_ T•77LJ
<br /> PVB CONTRACTOR C I M -
<br /> 1 AODRBD J'a G PJC/
<br /> �( PHONE!
<br /> t TYPE Of WEM V1MP. FFEJT�T NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER
<br /> tel/ L/J .01 INSTALLATION ❑WE/LL SYSTEM RWMR ❑CODAS'CONNECT REPAIR ❑ VAPOR EXTINCTION wELV
<br /> U</U ❑NFw❑RT.b N.P. / J
<br /> RYPE OF PUP {p[�t DEPTH PIMP PET_FT. FIRST WATER LEVEL O
<br /> µ .1 w ❑ OMOr"ALICE WELL ❑ SEORIYSICAL WELL I r ��❑,_SOIL BORING `—
<br /> �p�FI 'I _ B..
<br /> U bESTPVCTION:P
<br /> INTFNOED UEE fI TYPE OF WE CONSTRYCTION L,E IHCATIOW
<br /> ❑ INDUSTRIAL SII ❑OPEN BOTTOMA
<br /> DIA.OF WELL EXCAVATION DIA.OF CDNOMTOB CASINO+ D 1
<br /> ❑ DOMESTICORIVATE •L7ORAVEL PACK/SIZE TYPE OF CASIMME,,,w PvG GIA,OF WELL CASINO V
<br /> ❑ RIBLICMUNIC�� RWEN bEPTH OF GROW MALL SDA RAL ❑Or c' D
<br /> fYyyCC BE4CIFICATION
<br /> .0 •J'IRRIOATbN/A(J []OTHER
<br /> SEOTHEfl GROUT AL INSTALLE�,sIy �/V FL�L(—ry, GROUTBRAMNAMESL1/HLCA-7L E
<br /> ❑ MONITORING ARGUE PEAL PUAIFEO:Ely. ❑N. CONCRETE PEDESTAL BY ORIILER: Elm.Y. 8
<br /> APPRGX.DEPFN_) Z p V LOCIINO CHMITTA BOX/STOVE Mn_
<br /> If5
<br /> P11OPOi®CONtTJRUCTIONlOPtVMO METHOD: MUD IIOTARYX_AIR ROTARY AUGER CABLE
<br /> alOTHER
<br /> ' I HERESY ON9 OY Y11AT I IIAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAH JOAWIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND
<br /> REGVLATIOND OF THE BAN JOAOUON COUNTY, HOME O,,Fn OR VC,,,MO AGENT'S SRINATVRE CERTIFIED THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF VIE WOW FOR WUCH
<br /> THIP PERMIT IS ISSUED,I BEAU NOT EMPLOY PERSONS SUBJECT TO WORKMAN't COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR 8V&COHTRACTIM SIGNATURE CERTIFIES
<br /> THE FOLLOVNNO: :111 CEMIFY THAT L IN THE PERFORMANCE OF THE WGPL FOR WHICH THIS F,,,W IS IMBUED.1 SHALL EMPLOY MAMINS SUBJECT TO WCBMAAN'17 COATRNGATION LAWS OF
<br /> CAUFMHIA,• EHEI:'PLICA/y/,T MUj/j/L//T CALL XA HOURS IN ADVANCE FOR ALL 11EOUREO' I1fNA,,,, 1oNS EAST IZSMI.SSJEZi, COMPLETE DMWIM AT LOWER ARA PROVIDED.
<br /> 423.
<br /> 1 fflft X----` ./�/L/QL D.I. 3-30- q�
<br /> PLOT PAN IOr....I.Soa l Be.l. •N
<br /> I. NAMES OP PTREETO OR ROADS NEAREST 1001"BOUNDING THE MOMMIN,
<br /> Z. OUTLINE OF THEIPbEERTY,OILING DIMENSIONS AND NORTH DIRECTION. A, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR proMSEO
<br /> OWENS'ONED 05/ItO49 AND LOCATION OF ALL EXIRINO AND PROPOSED EAPANIMN OF MWAOE DISPOSAL SYSTEMS.
<br /> STRUCTURES,INCLUDING COVERED MEAS SUCH AS PATIOS,DRIVEWAYS,AND IM, ` S. LOCATION OF WTI LD WITHIN RADIUS OF ONE NUNpRO FIFTY FT.
<br /> a. NO O
<br /> ON THE FRIGHTITTY On
<br /> _... /d
<br /> .. .amu.+-_ .. . NA
<br /> q.........,.' ai - IM PR
<br /> a ...... .._...... >......,.
<br /> .... 1..>.. .: ....... .. ... .. a.....;..:
<br /> .. ......<.......... rb..°.. .' o ......
<br /> :.....>...._ .. :....:.. ..o.. .. ... >: :..:.'.b::. ;. plef .. 001
<br /> a.. .:. . :.. ....>.....:.....>.... ......:...........
<br /> I
<br /> i
<br /> ail E
<br /> sir Y�
<br /> :
<br /> : : ..: .. :...:
<br /> b.... .... a....:.....x.......... ......:.
<br /> ........r. ..... .....:......e......:......b......;......' .
<br /> 7
<br /> i .. ...'.. ' . l
<br /> i i ( i i i :
<br /> ....;.�/.... ..b...o.............
<br /> i
<br /> .
<br /> i
<br /> 'Sf.... ...........:.....c.. ..;............y.....x....:........
<br /> i
<br /> . .:....i............b... :...........:.............'... .......(....<
<br /> Vj
<br /> :.......:.. . .. .:......<......;......;.....;.....:.....;...... ......;......;..... .....>.....:...... .. ..... .::y::: .A :..3.: .1992.:a.
<br /> ..!
<br /> p
<br /> t .....2• _���••�.if�!.<.-;,-•.s r;++ei,<�P�.s',-'r�c' .. .„... b
<br /> ..........
<br /> PUBLIC HEALTH SERVICES
<br /> DFIMTMENT VSE ONLY IY
<br /> APPIIcaB Mee W B -
<br /> �
<br /> G,.0 F»PF.II.n eT G.e. F f,3/y PUn.m.PmG.n eY
<br /> oA»
<br /> ACCOUNTING ONLY! AID# FAC# Iq /rir( 4btiL• Oio•a.GF.r� q(PA4g/f.<C 3
<br /> ' PyYECOOED FII INFO AMOUNT REMITTED QIECN CAS. RECEIVED BY DATA PEIAMIIISFAVICE PEGUEtT NIMSDR INVOICE 4
<br /> IY�I_T) t� • L7
<br />
|