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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES � ENVIRONMENTAL HEALTH DIVISION 304ST WEBER AVENUE,STOCKTON, CA 9 202 (209) 468-3420 NON-REFUNDABLE PEEWIT EXPIRES I YEAR FROM DATE ISSUED (Complete In TT{pDeetel , APPUCATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 15 MADE IN COMPLIANCE WIT}H CAN JOAQUIN COUNTY DEVELO NTT A yLI I S.3 AND THE STANDARDS OF SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. I eG PARCEL 92APl-7aeK[sJOB AUMMSOR APN/ 3 OWNER'S NAME h1 5a Q 'r k— ADDRESS (�r�Q� J� p f I, v q'4 / A PHONE CONTRACTOR YI{ Vr, m \ .Lr �/ ADDRE86_/.J�_-rT-V�T`_-R[� (+I �tjCl /(eTPf10NEfS BUB CONTRACTOR ADDRESS LICE RHONE f TYPE OF WELI/PUMP•, 0 NEW WELL ❑ REM ACEMENT WELL ❑ MONITORING WELLf ❑ OTHER ❑ ENSTAUATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I 1 (TYPE OF PIMP ".13❑NR.p.1, H.P. DEPTH PUMP GET FT. FIRST WATER LEVEL O ❑!ow-OF-SERVICE WELL o _ ❑/OOPHYwcAL WELL I � SO4 BORING G: 0 S :7ywfU-❑OBRCTONe INQS ci *Af- INTENDED USE TYPE Of WELL CONSTRUCTION SPEWFICATIONS[� r A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 7 , OIA.OF CONDUCTOR CASING !w•1A, p ❑ OOMEGTICM MVATE ❑GRAVEL PACKAITLE TYPE OF CASINOISTEELIPVC OIA.OF WELL CAGINO p ❑ PUBUCIMUNICTPAL ❑DRIVEN �� , DEPTH OF GROUT SEAL G SPECIFICATION R 13IRRTGATIONIAG OTHER C1 i rLS GROUT SEAL INSTALLED BY r1, GROUT BRAND NAME E MONITORING1 •7 GROUT SEAL PUMPED! PqYe. [IN. CONCRETE PEDESTAL BY DRILLER:C1 Y. XNe 5 APPROX.DEPTH 10—/1LOCKING CHESTER BOXIMOVE PtPEL J S PRMPOSEO CONSTRUCTIONM ILUNO METHOD! MUD ROTARY AIR ROTARY AUGER CABLE OTHER d re Ii�IdrttullC ha.n>~ear 1 HEREBY CERTIFY THAT I HAVE PREPARED TM8 APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COTINTY ORDINANCES,STATE LAWS,AND RULES ANO REGULATIONS OF THE SAN JOAOUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWBJO,'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IG ISSUED.I SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HANG OR SUB CONTRACTwo SOHATURE CERTIFIES THE FOLLOWING; •1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMrr IB 18BUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 ItRURIp IN AWANce FOR ALLREQUIRES INSPEC71bNS AT 120e1•403422- COMPLETE DRAWIfHO AT LOWER AREA PROVIDED. v 1 Slen.e xLi trt.4" TitH F/Ili: JC1P►'ti�'i,�;I,_ ^ PLOT PLAN IOr.w to saoW Sed. •to I, NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DIGPOSAL SYSTEM OR PROPOSED 2. OUTTLINE:OF THE PROPERTY,OfVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DfSPOSAL SYSTEMS. 9. DIMENSIONED OUTLfNFB AND LOCATION OF ALL EXPITITM AND PROPOSED S. LOCATION OF WELLS WITHIN nAams Of ONE HUMORED FIFTY FT. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING P apEftTY. F4 cliked ::.. . . :.....:.... DEPARTMENT USE ONLY Appllanbrt Aeeepld By � ,`� A,r�J`�• Gr.nU Mnpe.rlen By �� Date Puny Irr.pmtfen By QN. De.rnretlen I..geclen By Qn■ ACCOUNTING ONLY: "NDA R FACT A/ sE CODEs FEE INFO AMOUNT REHSTTES CN ASH RECEIVES By DARE Pg1MPTnFRvtCE REQUEST NUMBER INVOICE f, Pub.Health Serv.-Eriviro.173(1/97) y