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nr r uvn IRun run,wcLwrvmr rcnwni <br />zoo /Rowe SAN JOAQUIN COI ?MVUBUC WEALTH SERVICES <br />ENVIRONMENTAL HEALTH OItISION � <br />904 EAST WEBER AVFi M STOC'KfON. CA <br />(20% =4= mrd F1oW <br />NON-REMMOAREE PEBMR <br />APPUCATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT A=M !!STALL THE WORK DESCIUSED. THM APPLICATION SI MADE EN COMPUAHCE MATH $A► <br />JOAOUIH COUNTY DEVELOPMEHT TITLL CHAPTER 9-1115.1 AND THE ItrANDAFtD* OF SARI JOAOUIN CotWrY PUBLIC HEALTH SERVICES. EWFIONMENTAL HEALTH DPAWA N. <br />JOB ADDRESWOR, AP NI_ Z CITY PARM s2ErAPNs <br />OWNER'S NAME !� %t ADDRESS �... _ /�_ /, J y06 PHONE41, <br />—, <br />cONTRACTOa / 7 ADDRE.- �i'aiT�D.?i'✓ UCS � A PHONE F(j�22 f 9/e5 <br />CUB CONTRACTOR %/-.' ('i fi �n Sc..n,�:.� S.�c/ //i'. /�i�i� <br />ADOIEss �/ / •, f t fy S t'�fLMics C'-3� 6 $� i �t� PHONE 4(415-) =5-5- -9f <br />TYPE OF WELLX UMP- ❑ WW VARL ❑ IEPLACEMENr WELL ❑ MoNIrQNwo WELL 8 - <br />❑ SNSTALLATION ❑ WELL SYSTEM PErAm ❑ CROW4ONf*CT REPAIR <br />® OTHER_ C /�"T- <br />❑ vA.DR EXTRACTION WELL P <br />❑ Nero ❑ Rrgek H.P. DErrN PUN►BFr FT. <br />I FIRS11 WATER LEVEL <br />. <br />� C <br />RYPE OF PVfMPI <br />❑ OVT-0I� WELL ❑ GEOPHV=CAL WELL / <br />80A SOISND _ c� �=L' / 7-"T- <br />C B <br />❑ DEBTIR cmw <br />L4 ro ; ar F- 5 /; rt <br />--/��aa <br />INTONDIID USE TYPE OF WELL CONSTRUCTION sFECWCAT1pNa <br />❑ wouc RIAL ❑ OPEN BOTTOM DIA OF WELL E%CAVATION <br />DIA. OF CONDUCTOR CASINO <br />❑ OOMESTICIPRV VATS ❑ WMVEi P^CKM .F TYPE OF CASOKLMTEB V VC <br />OIA. OF WELL CASING <br />D <br />❑ PU8UClMUNICIPAL ❑ DRIVEN DE"M <br />}�^! <br />OF GROUT SEAL <br />SPECIFICATION <br />R <br />❑ MMOATMF41AG ❑ OTHER <br />OROUr SEAL NSTALJiD B'Y <br />ORDII'T BRAND NAME <br />13 MONITOgMO GROUT SEAL PU%Q D: ❑ Y. ❑ N. <br />CONCRETE PEDESTAL, BY DRILLER@ ❑ Y— <br />` <br />❑ N. <br />APPRoIL DEPTH LOCIOPIO CHESTER SOXMTOVE <br />PIPE <br />S <br />S <br />PROPOSED CONSTRUCTION/DISLAING MUH1013 MUD ROTARY AIR ROTARY Y AUGER <br />CAM OTHER <br />Zc/ —,4 <br />I HEREBY CEIaVY THAT I HAVE PIEPAAW TIRO A^TION ANO THAT THE BE DONE N A006fwAmcE <br />MArH SAN iDAOVIN COUNTY OmwANCEi. STATE LAWS. AND RULE$ ANI <br />REGULATIONS OF THE SAN JOAOLRPI COUNTY. OME OWNER OR LICEmMD SIONATURE CERTIFIES THE FOLLoww ; I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHIG <br />THIS PFTONR 38 16:11M, I SHALL NOT EfEP'U)Y PERSONS SUBJECTTO WOR MWM CoMpa"A,TION LAWS OF CALIOW"-- CONTRACTOR'S HIRING OR WS -CONTRACTING SIGNATURE <br />CFRTIAE: <br />THE FOLLOWING: ' 1 CERTIFY THAT M THE PEAFO}MANCE OF THE WORK FOR N1H1CH THIS PEftRT R ISRAM. I SMALL EMPLOY PERSONS SUBJECT TO WOM MAWS <br />COMPENSATION <br />CAUFORMA' THE APPLICANT MUST C 24 No N ADVANCI FOR ALL RX0tX= TNN4r1S AT CIM 46@-24= COMPLETE DRAWMNO AT LOWER AREA PROVfM. <br />LAWS O? <br />LLCM <br />Slo .�d x Tttl. ST4 7T S L' r i/ <br />/. <br />Ti T <br />; y <br />ROT PLAN Mc to So" Smie � r <br />1. NAMES OF STREETS OR ROADS W-AAEST TO OR BOUNDING THE PROPERRfY. <br />t. LOCATION OF !OUSE SEWAGE DISPOSAL SYSTEM OR PROPOSM <br />Z. OUTLINE OF THE PROPERTY. QNISNO 011611ENNONS AND NORTH DW*C I N. <br />- EXPANSION OF SEWAGE DISPOM SYSTEMS. <br />]. OIMENS30NED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />S. LOCATION OF WELLS WITHRI RADIUS OF ONE HUNDRED FIFTY FT. <br />CrRUCTUf1Es. INCLUDING COVER M AREAS SUCH AS PATIOS. DRIVEWAYS. APO WAIXL <br />nu ��ae ori—.ry ...... .......... s....'...., <br />08ARTM9NT LTE 0110 <br />Aoollaetbn Aaoegtad by 1111Y�NL1�l11i�1 1(A iLi peN L' -,In Ar- <br />O.—ft In.p.atlen By Dec. PteIIIU tnea.ctlen Bq <br />Date <br />Oscntedon Wwq.otkm ey DeN. <br />ACCOUNTING ONLY- ' AIG/ ! FACS <br />PE CODIM FEE INFO AMOLMT PCOWETTm CMW"iCASH RECOM ST DATE 1S6tVICE REQUEST NLSMS9l INVOICE <br />0� <br />Z "d SIGMA WdZ©= Z 8661- L Z -Z L <br />