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k <br /> � <br /> APPLICATION FOR LPERMIT <br /> SAN JOAQUIN COUNTY PUBLIC <br /> IC HEA HEALTH SERVICES (� <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 ORIGINAL <br /> (209) 468-3420 <br /> ROR.REFURDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICapViBtB M TTbIN+ul <br /> APPLICATION IS HERE RY MADE TO TME I IJ�I JJOAOUIN COLSNNTYY-FOR A PEWIT TO CONHTi T ANOMR INSTALL THE VION(DESCRIBED.Ti09 APPLICATION 19 MATE IN COMRIANCE WRII SAN <br /> O!AOO"AWNCO VOR AM L, I 1 �� IV rµ��I1'TI UTNE grl\ (� S Of SAN JOAOUIN COVNEY �IIEA(.T'SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> VL /�/A/E / PARCEL SIZFJAPN/ <br /> A.M4 Z a✓Q K n h; AUOREBSC P 0 9 o/. [P b PHONE I 6 — 3 <br /> CO MRACTDprs ME J J/f I,, ��0227 �J <br /> AFIUQ C 6Cf �h ON C I ADDRESS fI/aS U. V,II�VN WIIV LIC/ V�([L�/_PHONF/ r67�66 <br /> ADOIEp UC/ PHONE/ <br /> O IIIR: R <br /> TYPE OF WELLMJMP. ❑ NEW WELL. ❑ RPIACEMEW WELL IOMTORNG WELL/ V ❑ OTHER <br /> 13INgrAWTIOry ❑ WELL SYSTEM REPAIR C] CROB6COHWCT REPAIR (:3VAPoR EXTRACTION WELL/ J <br /> ❑N.w❑ N.P. DEPTH PUMP 9ETFT. FIRST WATER LEVEL O <br /> ff P OF RIMM ❑ OUr-oF- bE WELL ❑ GMFN Gm^L WELL/ ❑ 801L ROPoNO [ <br /> ❑OERTINCTION: A/ / <br /> INTENDED USE TYRE OF WELL CONSTRUCTION EPfC1F1CATION[ _AHC VIA.OF CONOUCTORCA81N0 I-/R A <br /> ❑ �HOUSTRAL ❑f.PEN BOTTOM ( DIA.OF VIED ExCAVATION O <br /> ❑ DOMESTICIPRVATE �0RAWLPACIUSIZE Saw TYPE OF CABINOMTEELiN PV L1 DIA.Of WELL CASINO L- wK D <br /> ❑ R BUCMUN CNAI ❑cnr Em DEPTH OF OROVT DEAL Y IA f ILK! 1 U S I SRCO CATbN SC L I( 1 R <br /> ��❑Ilrr IRRIGATION/AO ❑OTHER GROUT BEAL INSTAIIIED11 TIC HII f ORO FT MVWD NAME OVYfI��Aqq.//4 E <br /> MDNITORNO I GROUT SEAL PUMRo:gy— ❑Ns I com ETEED <br /> FESTAL BY ORRLEIRIO.Y� ❑N. s <br /> AIPMO x.DEI`TN LO JNO CHESTER SOXMOVE RPE k <br /> Will' .X S <br /> PROPOSED CONSTRUCnOMIdBlLNO METHOD: MUD RUTARV AIR ROTARYAVOER_X CABLE OTHER <br /> 1 HEESY CERTIFY THAT t HAVE PRIEPAIED THIS APRJCATIK N ANO THAT THE WORK WS-IL SE DOME M ACCORDANCE WITH BAN JOAONN COUNTY ORDINANCES.STATE LAWS,ANO RULES AND <br /> RGVIATIONS OF THE BAN JOAWN COUNTY. HOME OWRIER OR UCErySED AOEW'S MONATURE CFRINES THE]FOLLOWING!'1 CORNY'THAT W THE IEKORMANCE OF THE WORK FOR W H <br /> THIS PERMIT IS ISSUED.I SNALL HOT FMFLOY PERSONS SUBJECT TO Wp IKIMA I'S COMREPRATION LAWS Of CAUFOIMA.' COWRAROR'S HTRFb OR BUS{OWRACTNO SIONATUIE CERTIFIES <br /> THE FOLLOWING: -I CERFIVY THAT M THE RRFORMANCE Of TW WORK MR WHICH TWO PERMIT IB ISSUED.I SMALL EMR.OY PERSONS SUBIECT TO WNI SMAR'B COM/EIESAMA,LAWS Of <br /> CALIFORNIA' TIE TAW UST CALL 24 bIRS IN MOVING[FOR LL RdS Cb <br /> n:WpKA �I !,(� ON S1V4411G4Mn. MMRETF DRAWING AT LOWER AREA N`KHSKED <br /> G <br /> z — G . q <br /> ROT RAR 10,.W1.B..I.I B..N. 'M <br /> 1. NAMES Of STREETS OR ROADS NEAREST TO OR SDUNOINU TIE PROPERTY. A. LOCATION Of SEWAOUSEGE <br /> BEYVAOE ALOIS6VTTI SYSTEM OR RIDIOSED <br /> Z. OMLS E OF THE PROPERTY.DARNS p HII ONB AMD NORTH ORECTION. E%/ANRON OF SEWAGE DIROSN SYSTEMS. <br /> ]. DIIEMBIpEO OUTLIMFS AND LOCATION Of ALL E%1STNG AND FPIOF08EO E. LO TION OF WELLS WOHN RAORIS Of ONE MRFORED FIFTY FT. <br /> STNICT111ES.NCLUDINO COVERED AREAS SUCH AS PATIOS.ORVEWAYS.MID WALKS. ON THE PROPERTY OR AOJOININo RbF'F11TY. <br /> DEPARTMENT WE ONLY <br /> Ae.u..,a.,Aeeepled Br ON. � '` L �G / A... <br /> 546/7 <br /> D..�.��n...IrwPSllm er <br /> / D.I. <br /> —t,6 <br /> ACCOUNDN.ONLY. MD/ FACI <br /> R CODES FEE INFO AMOINT REMITTED CMECFCFMASH RECOVEO BY DATE POMITISRTVICE REQUEST NUMB RI INVOICE _ <br /> 350 ICU 11 �s1. 1 3— t - <br />