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-----l- ----II Irl -1-Lin-n-LO !x ENVIRONMENTAL HEALTH DIVISION T `OX 389,445 N.SAN JOAOUIN ST., STOCKTON,CA 951P 1 �.► (209)468.3420 N-O/ M )n NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED t'NVIR(X, TAENIAL I If-ALIH (Compl$tE in TTiplkEtol RRlvlll/SERVICES APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITTLLE,CHAPTER 9--1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB A DDRESS/OR AAPNI la//SI/ it/ S7� /� CITY //YrCPU,iy PARCEL SIZE/APNI OWNER-6NAMEAAr��JC"'I{V ///4'(�JJ/' ADDRESS 427,}-D W• 5VjQO �pKI /�*� PI10NEI CONTRACTOR vlj/(�,�TJ C.$!r/GN(//eCH/ J�}7�//,(,JL ADDRES6��'jZiL(.1'/2�1a! j:Oj PO4'jCI PHONE ITS1-1 T4W �(lIE/l. ,li �,+'�Ldrt,1/?7! SrOC-Gl'�J�-.A X1520'J SUB CONTRACTOR ADDRESS 3�y/ J �• (vcZ7zv OHONE I.lS.LL�� %T.�dG.&2 ..i aD'aT77 TYPE OF WELUPUMP: ❑NEW WELL ❑REPLACEMENTWELL ❑MONITORING WELL/ ❑OTHER 1 11 INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL I ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D v�\1 (TYPE OF PUMP) 0 ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELLI ❑ SOIL BORING S DESTRUCTION: /j� !i�! MUA/• W�LC+S� r }J- INTEN ED USE TYPE OF WELL CONSTRUCTION ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATIONDIA.DIA.OF CONDUCTOR CASINO D f ❑DOMESTIC/PRIVATE GRAVEL PACK/SIZE TYPE OF CASINGISTEEUPVC DIA.OF WELL CASINO D ❑PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION_7'� }� R T�I IGATION/AO ❑OTHER GROUT 6EAl INSTALLED BV GROUT BRAND NAMEQ6.�� E MONFFORING n S GROUT SEAL PUMPED:❑Ys [IN. CONCRETE PEDESTAL BV DRILLER:❑Ys ❑No S _Oma`/ APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE s. PROPOSED CONETRIICTION/ORILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILT.BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH O THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIE161 THE FOLLOWING: 'I CERTIFY THAT IN THE PER OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' AP CAN UET CALL 24 LIR$IN ADVANCE FOR ALL IIEGU1AED LOTIONS AT(22000011468-3423.COMPLETE DRAWING AT LOWER AREA PROVIDED. ne [j SlOd% Title Date PLOT RAN(Draw to Goal.)Scala 'to TO ` 1. NAMES OF STREETS OR ROADS NEA OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. I� STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. �l RECE11lf=,n MAY 4 1995 COUNTY pun li.p,-A:LTH SF..RVIf F: EPl` {IrIJh.Li# 4;_11VISUN I DEPARTMENT USE ONLY y/ Application Accepted By Dete Ars Grout Impaction By_ Date Amp Impection By Data /\ Dstruetlon Impeetion By Data / C—rcenta: ACCOUNTING ONLY: AID4 FAC$ PE CODES FEE INFO AMOUNT REMITTED CHEC CASH RECEIVED Sy DATEPERIMIT/EI3IVICE REOUE$T NUMBER INVOICE