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SAN JOAQUIN COUNTY PUBLIC HEAL ° � <br /> ENVIRONMENTAL HEALTH DI 1 10 ' ) J 5�G] <br /> EAST WEBER AVENUE;STOCKY (1_L� �y,'�r 11314 <br /> (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in TrbEcnis) <br /> AP'UCATION IS HEM BY MADE TO THE SAN JOAOUIN COUNTY FORA PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORC DE6CPoBEO.THIS APPLICATION IS MADE IN COMPLIANCE WITII SA <br /> JOAOUIN COUNTY DEVELO�PME�NT TRLE:CHAPTEI1 S-1`116.3/AKDD THE STAND 0 OF SAN JOAOUIN CO(UUNTY PUBLI,CHEALTH SEHVICE6,EWPONMENTAL HEALTH OPASION.p _ . . <br /> JOB AODRESSMA AAPH'A5F}v��Q /.,JAG11 I•' �,/��m' V/W��ISM PARCEL SIZEJAPN• {MG�•.J�C'o u-, <br /> '+I�, <br /> OWNERS HAME`'OA�/•Nl.��.1��/I /_^B�-P��•L///G/6IIt5 ADORESO 11 j� a.1/J��, IJP �'ti RN)T�NfEP�/�I�Y/C' .i11T- <br /> WaL IMP R�'�F�/I1C�l.(L77�'R� � �L� ADDRESS /.� /'��Q// ��O Y�!•`I��+� <br /> �(t1 r <br /> SUBCONTRACTOR ♦V)GP IFI^ n 11pp AODI1E68 - �./L.�'R�/���.Cf'�Fj1 9�OS_UDeC57-S/�.76 PPHaNE/?OY-Y6.S-i <br /> TYPE OF WELL/R1MP: 0 NEW WELL ❑ REPACEMEM WELL W MONITORING WELL/ /�/% ❑ OTHER <br /> ❑ NSTALLATION ❑ WELL SYSTEM REPAIR ❑ CM,H6 ONHECT REPAIR ❑ VAPOR EXTRACTION WELL S - <br /> N A ❑N. AaPW N.P. DEPTH PIMP 6ETA/�M- FOIST WATER LEVEL <br /> rr P OF PUM% <br /> ❑ SVT-OF6EAVICE WELL ❑ OEORIY@CAL WELL/ ❑ 60R BORING E <br /> ❑DESTRUCTION. <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DtA.OF WELL EXCAVATION �Gff ++ff OIA.OF CONDUCTORCASINO iU/A C <br /> ❑ DOMESTICREV VATE ®SNIVEL PACKfeRE 6 TYPE OF CASINOISTEEI_: ( II 5YG f-V�_ GIA-OF WELL CASING <br /> ❑ PUBLIGMUNICIPAL ❑D0R/EN OEM"OF GROUT SEAL TT.SG f SPEOIFICATION µ f <br /> ❑ IRRIGATK)HIAO ❑OTHER GROUT SEAL INSTALLEb�JBBtB Y'1 r/Ile r GROUT SAND NAME Afa L Ce m eAJ{� E <br /> ® MONITONNO GROUT SEAL PUMPED' Id Yr ❑NP CONCRETE PEDESTAL BY OPI IN Y- C3 N. - <br /> APPROX. OEM- FO LOCKING CHESTER BOX/S'TOVE PIPE I/FCC <br /> PROPOSED CONSTRUCTIONRNBLUNO METHOD: MUD ROTARY AIR ROTARY AUGER )� CABLE OTHER <br /> - <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAQURN COUNTY ORDINANCES.STATE LAWS,AND RULES A4 <br /> nfGULATION5 OF THE CAN JOAONN COUNTY. HOME OWNER OR LICENSED AGEIR'S BIGIIATUPE CERTIFIES THE FOLLOWING:"1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FGA KN{ <br /> THISPERMIT IS RSSUEO,1 SHALL NOT EMP,OY PERSONS SUBJECT TO WORKMAN'S COMPDI6APON LAWS OF CALIFORNIA." COWMCTOR'B HIRING OR GUBCOWMCTINO SIONATUM CEF iii <br /> THE FOLLOW( I CERTIFY THAT IN THE PERFORMANCE OF THE WOW.FOR WHICH THIS PEWIT to IBSUED.I SHALL EMPLOY PER6WPS SUBJECT TO WORIOMAN'S COMPENSATION LAWS <br /> CAUfOnN' T APPICA MU T C14 24 HOURS INA VAHCE FOR ALL REQUIRED(IINSPECTIONS AT IZOSI AS41J405. COMPETE OMWINO AT LOWER AREA PROM EO. <br /> SI.. x 'T� I // 1�•/LI Q--/?� ._._sln. �)ifC ?r'D'PA T/ Ma Na TEP l' D.I. /L% <br /> v �J <br /> MOT PLAN e6eWl 6e•b "to _ <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROTERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On P MSEO <br /> Z. OLRLINE OF THE P,,KRry.OMNO DIMENIPGRe ANO NORTH DIRECTION. EXPANSION OF SEWAGE OISF06AL SYSTEMS. <br /> G, DIMENSIONED OVTUHF.6 ANO LOCATION OF ALL EMSE)NO AND PROPO6E0 S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLUDING,COVERS AREAS SUCH A$ATOS,E)PLVEWWA.YS.AND WAIXB. ON THE PROPERTY OR ADJOINING P PERTY, <br /> MRP 1�ft0. a� e �C. <br /> DEPARTMENT USE ONLY <br /> OraVI b.Pa.Ib..B. On. P.nP ImeaFlbn Br D.I. <br /> OsmsO.n Lnn.elbn BY Dat. <br /> Gn�nrn•n,.. �� �/R'`- ISD/� <br /> SJ G�04-v * F- coz-,:-✓ <br /> ACCO UNTINO ONLY: AID! FACS <br /> PE CODES FEETWO I AMOUNT REMITTED CHECKMASH RECEVED BY DATE PE MITMERVICE REQUEST NUMBER INVOICE <br /> Z40 tU tJ i Z- <br /> l0 <br /> I <br /> Pub.Heath Sam.-EnvirG.173(1/97) <br />