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�N JOAUUIN COUNTY PUBLIC HEALTH SERVICEL ENVIRONMENTAL HEALTH DIVISION R0. Box Sas, SD4 EAST WESE'R AVEMIF, ST KTON. CA 9s201.3W (209) 460.3420 NON•REFUNDA LE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete b Tripdic.r.l APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERLIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRINE0,THIS APPUCAT10N fi MA(i IN COMPLIANCE MYTH SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115,3 AND THE 11TANOARD6 OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ElMM14NA:NTAL HEALTH DIVISION. JOB ADOWSMOR APNJ 5 C-X' I �r1w Q.✓�.y H, L/'.-.ri sc �L��, jt=.•r-�_� cm 4 Cy 7/-t.^k� Com_ PARCEL 812EIAPNJ�`/�C� Cx- OWNEII'8 NAME / / . � PHONE J CONTRACTOR �CK ADDRESS Z 2C'/ f� `d rr � G ! F+WNE%�y/t L SUB CONTRACTOR ADDREti LICS PHONE TYPE OF WELLJPVIUP: NEW WELL ❑ REPLACEMENT SPELL ❑ MONMMNO WELL J ❑ OTHER �'.". ;ry Acc-.•.lJ:-�'�r fl.,rr g �'/'L ❑ wrrALLATION ❑ WELL SYSTEM REPAIR ❑ CRO98.CDNNECT REPAIR ❑ VAPOR EXTRACTION WELL r J ❑Naw❑Rw w H.p- DEPTH PUMP 8ET FT. FIPZT WATER LEVEL L; ;r O ITYPE OF PUMPI ❑ OUT-0F SERVICE WELL ❑ OEOPNYSICAL WELL J ❑ BOIL ROMNO B ❑DESTMic-r1DN: INTENDFD UOE TIePE OF WELL q;QN&TRUCT10SVEcmCATIONA JI ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_ /,/" DIA.OF CONDUCTOR CASING O ❑ DOMEBTIC/FAIVATE 0 GRAVEL PACKISIZE TYPE OF CAUINGWEEUPVC I IY-,) C.N4a. i�tt.Ow OF WELL CASINO^_ " �7L' .� D 11PVUUCIMUNICWAL El DRIVEN DEPTH OF GROUT SEAL 1'7'U'r SPECIFICATION ❑ IRRIGATIOWAG D OTHER — w'^"'//vJJ'��u��7��' GROUT SEAL INSTALLED BY rj^[17Y rr•.rev GROUT BRAND NAME E ❑ MONFTORINO lJ INAµ,} (�,, L��ROLFTT JCAL RJMPED:0 V_ ❑N. CONCRETE PEDERTAL BY MLUFt:❑YM ❑w S 1PNIO Y.DEiTH_ ,2.,C,C�•x'a 2 IV` V��1`�F' �/ 7"IIG�^ LOCKW40 CHESTER WXWTOVE PIPE 5 PROPOO D CONATR ICTIOWMAILLM01 METHOD: MUD ROTARY AIR NOTARY ,t AUGER CABLE OTHER I HE4ESY CERTIFY THAT 1 NAVE PREPARED THIS APPLICATION AND THAT THE WOMC"LL OE DONE IN ACCORDANCE M/ITH BAN JOAOUIN COUNTY OfIDINANCES, STATE LAWS.AND RULES AND REOVLATIONU OF THE SAN JOAOUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERPORUANCE OF THfi WORE{Foq WHICH THIS PfAWT IS IVUUED,I SHALL NOT EMPLOY PERBONU SUBJECT TO WORKMAN-9 COYPMSATION LAWS OF CALIFORNIA.- CONTRACTOMB HP9NG OR SU"ONTRACIrINO U10NATURE CERTIFIES THE FGLLOWNO: '1 CERTIFY THAT IN THE PEr6ORMIANCE OF THE W011K FOR WHICH THIS PERMIT 18 10UV'ED,1 SHALL EMPLOY PEP ONU SUBJECT TO 1NORI2AAN'B COMP@ISATION LAWS OF CALIFORNIA.' THE AVPUCANT MU 4T CALL 24 HOLIR&AwAOV i EOR ALL REOLSRED warm none AT tne)4o.s42s. COMPLETE DRAWING AT LAWER AREA PRoV1om, 6+9n.d z TM. /L', jo"L: ' D.I. KUP- I OT KAN 1D .v r. m S..w S.Nw. -w J I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <. LOCATION OF HOUSE SEWAGE 010MUAL SYSTEM OR PAopOUED OUTLINE OF THE PROPERTY,DIVING DIMENE401YU AND NORTH DIRECTION- EXPANSION OF 8EVI/A0E DIBPORAL BYOTEMS, J- DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOGEO 5. LOCATION OF WELLS WITHIN RADIUS OF ONE NVNORED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERT-Y, It Date Post i Fax Note 7671 page :.................. .... ;......,..... TOFrom IL :......i............. ... ...:....;.......:... Co./Dept. o C .. :..................; hone# hone# ' # Fax# E �....:...........<..... ......;....................... .... .. .... .s.......:...�,�i Fax I <.. i.. .... F 4`12-7 0 0 DEPARTMENT USE ONLY / MPIlun6n A'..--,LIN BY D.1. A r Oran In.P—V..r 61Y O.I. FV v I—D—l—B7 D.1. OwTrucLIPn kr L, *n Oy D■I. AC�Tu:7 ONLY: AIOJ FACE PE COOSA FEE INFO AMOUNT REMrTTED CHECKJICAAH RLCLIVIC By DATE P7l ATISE%ftE REOUEJT NUIVJ I INVOICE I I Z d ��lOrJ� Wd l Z�V 966 l—S�—V