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) ,SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P•O: BOX-388, 304 EAST WEBER AVENUE, STIOCKT . CA'95'201388` <br /> (209) 469-3420 <br /> i NON•REFUNDAR PERMIT <br /> �I <br /> JOAW TCM w HERE BY MAOE TO THE 6M JOAOWN COUNTY FOR A PEANUT TO CONRTRi1CT <br /> JOAOUN LOunrY p LoPMEHf AMOIN MBTALL THE WOW TMSCAIBED. ,EN IIIONM NTA,IS MADE IN COMRDAMCF WRH 6u <br /> T/1/TI�G CHASTE,,9-i 713.3 AND THE BTANOAROBfO�F 6M JOAWM COW+iY PVBUC NEµTN 6ETIVICEB,ENN110NMEMAL NEAITH <br /> JOB ADDRE6PAR1 AP1N/ 212{ I�Lt�/'�� Y�], I 'f1L.'� /�{�li1{Qp�. CRY �95�+ IG— P IMCE11�PtIF/Mf1I�'F T /��•l <br /> OWNERS NAME W.cuf�1 �VLQ I�Q /�I� I- h/f Y'S �,�J�App�BB ! CJ/� r\ ��_ ••�Gf��$.lo T /,(. <br />�. <br /> ^ ' PHONE <br /> �/ ♦ ��-O ���iJ CONTRACTOR CJ.Y'`S/°�Y' 1 i-.c AoonEss 7 '�� >m <br /> SUB ADORERS C/C A�V,.* <br /> .* ir0 PHONE i <br /> CONTATOR Y-O 9lG <br /> -9OY1��pa� PbHETClC�-I(vl�.. <br /> o'er <br /> TYPE OR WEL JMR ❑ NEW WFJ,L ❑ REPLACEMENT WELL d MONROIPrq YELL♦ ❑ OTHER <br /> ❑ MSTALIATbH ❑ WELL SYSTEM REPAIR ❑ CRoss CowNECT REPAIR ❑ VAPOR EXTRACTION WELL I J <br /> ❑Nwv❑Ry.lr N-P. cwrP %MIP BET FT. RBST WATER LEVEL p <br /> RYPE Of SUM% --- <br /> ❑ omT0i ommEwm ❑ OEOPNYIDCµWELL: OILlOWHO_ � R <br /> D DERTRUCTgN; <br /> INTENOm USE TYPE OF WELL CONSTRUCTION SPECINCATIONS A <br /> ❑ MDIIBTwµ ❑OPEN BOTTOM DIA,OF WELL EXCAVATION OIA.OF CONDUCTOR CASINO D <br /> ❑ OOMEPTIC/RPVATE \0 <br /> GAAVEL PACK=E TYIE Of cA81NO18TEELNVC cd .Of WELL CABNIO O <br /> ❑ PVBIKIMUNX;NAL }�J,pwVEH DEPFNOFOWVT BEAD sr ECIFIGTION p 1 <br /> ❑ SBSOATIOH/AG ✓❑OTHER OROVT BFAL MBTA Ire' OMUT IUUNO NAME E <br /> ❑ 1.10WTORIM �� _ �� ORDVT MAL PUMPED: ❑YM ❑w CONCI�TE FEOFBTAL BY DWl11R:❑Y. ❑H. S <br /> AFMDX IHTT1 N e LOc:E Nq CHESTER noxraroVE PIPE (T'-�� 1 S <br /> MIOPOSED CONST'SUCTHNPADRIIWNO AIET'MD: W R <br /> MUD NOTARY AW AUOER CABLE OTHER VT fGCJ 5 k <br /> I HPREaY CERYNY TNAT 1 NAVE PREPAAEO THIP APRICATRIII/JIG TNAT THE WOW W BE DONE IN ACCOROANCE WITH SAH JOAG.COUNTY ORDINANCES,STATE LAWS.ANp RULES AMC <br /> RFOVLATH)"OF THE RAN JOAQUIN COUNTY, HOME OWNEA OR LICENSED AGENT'S SIONATUPE CERTNIEB THE FOLLO%J :•1 CEJTRFY THAT M THE PEMOIu1ANCF OF THE WOW FOR Y MH <br /> Me PERMIT IN <br /> ISSUED.1 BNALL NOT EMPLOY FEMONS SUSIECT TO WORSTAIIN'S COMPdSATIOM NWB OF CALIFOMIIA-• CONTMCTORS MwNO OR SUBCON INO SgNANRE CEFTFlEf <br /> THE FOLLOVRPq: •1 CEJTfDY THAT IN THE KFIFORMAMCE OF THE WOW FOR MAIICN THIS FFN.IIi IB ISRVm.1 SHALL EMPLpy PETLSOMS NBJECT TO WORKMAN'S COMIWMTNJN I.MYB OI <br /> DAIJIORMA' TIDE A��RI�CAN}pMOST <br /> �CALL]M MuirN( VAr FOw ALL MO RRED MSRKAT�OMF At IpFI�gyZi. COMPLETE pM1MM0 AT LpvlEn ARE/.FTOVIDElD'. q <br /> u_\T` <br /> RDT FLAN IM.w a Ball fo,.1. 'b <br /> I. NAMES OF STREETS OR ROAOB NEAREST TO OR BOUNDING THE gbPEilTy. f. LOCATION OF MUM SEWAGE DIBFOSAL SYSTEM OR PROIOBED <br /> 2. OUTIJNE OF THE FFIOFCN .GIVING OMIEN N8 AND NORTH DIftcmN. EXPANWON OF SEWAGE DIBPO6AL SYSTEMS. <br /> 3, DIMENSIONED OUTUNF,P AND LOCATION OF ALL"IvTND AND PROPOSED 6. LOCATION OF WELLS WTTMIN RADIUS OF ONE HIINORED FIFTY FT. <br /> STwJCTU1D5,OP:LUDIMO COVETED AREAS SUCH AS PATIOS.DNV AYS,MIO WALXB. ON THE PROPERTY OR AOJOIMNO PFIOPERTY. <br /> .. .._ �..... ..... <br /> Post-i Fax Note 7671 Dat If ogesf 1, I <br /> Tp IIr„ From Keit pPALi <br /> .. Co./Dept. Ca <br /> " "_ " t Phone# Phone# U _ <br /> .. _. Fax# Fax <br /> I ..._.. ... <br /> • <br /> DFyARTM(WT USE ONLY <br /> AOHIWIIT AcwFled a. .D <br /> D.N. !•ZTI'� 1 N.. <br /> Me.n urF.Mbn RY-- — �Wo/ DM. I PMnP 4ve.Nlm BT D.0 <br /> DsHYFDbR" I—a bl. <br /> i <br /> ACCOUNTINO ONLY: Aip/ FACT <br /> R COD" FFE INFO AMOUNT�m CNECKS/GASH RECO, BY DATE R TNERNCE REDUEAT NUHSBI INVOICE <br /> lADO\ <br /> d h4nd- i'JdL-:;C L66 t -I <br />