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WIN COUNTYPUBLIC HEALTH SI M=-ES E:' ARONMENTAL HEALTH DNISION' .' X . �i WEBER AVENUE,STOCKTON, Cid �?2 (209)468-3420 110111-REFUNDABLE PERMIT EXPIRES Z YEAR FROM DATE ISSUED I (Complete In TrIplicatel I 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 DEVELO /PMENT TITLE,CHAPTER/9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTYPUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOS ADDRESSMR''APAAN, { ( CITY �jg744 I .(e PARCEL SIZFJAFNI OWNER'8 NAME 1--q� -w ti� AD1RE8S—Fb 10`d`1 / RHONE R +c a CONTRACTOR /GPib AODREBB&)--- A /��11.144& LIC/ pHONE'w✓ / RUB CONTRACTOR If AODRE6� �Z tT F CECT �-+� TYPE OF WELLIPUMP, ❑ NEW WELL ❑ REPLACEMENT WELL 1J MONFTORINO WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ❑fs o ❑Rapab H.P. (TYPE OF PUMP) DEPTH PUMP SET FT. FIRST WATER LEVEL p ❑ OUT-0F-SERVICE WELL - ❑ GEOPHYSICAL WELL# ❑ SOIL BORING R DESTRUCTION; T• „S INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION* A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_ �t 1 DIA_OF CONDUCTOR CASINO p ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISTZE TYPE OF CASINOtSTEELIPVC DIA.OF WELL CASING ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION ❑ IRRIGATIONfAG ❑OTHER GROUT SEAL INSTALLED BY-,Q� i GROUT BRAND NAME ❑ MONITORING fff GROUT SEAL PUMPED: G..II'r. ❑Na CONCRETE PEDESTAL BY DRILLER:❑Ym ❑Na S APPROX.DEPTH�T^ ld']+1 2k) LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONIDRILLINO MET14OD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER, 1 HERESY CERTIFY THAT 1 IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOVIN COUNTY ORDINANCES.STATE LAWS,AND RULES ANO REGULATIONS OF THE SAN JOAO"COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'*COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HBVNO OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLROYNNQ: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE1A{PPLjI�CANT MUST CALL HOMIS 1N ADVANCE FOR ALL REOUIRED INSPECTION/S AT 12RM14aa.S122. COMPLETE DRAN_ANO AT LOWER AREA PROVIDED. Q Slvn.d X � C�C1rr� TRIG Dna 1 PLOT PLAN Ids to Se.NI Beale 'is I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PnOPOSEO L 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXIffr!NG AND PROPOSED S. LOCATION OF WELLS WITHIN RAOMS OF ONE HUNDRED FIFTY FT. I'I STRUCTURES,INCLUMNO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAXXS. ON THE PROPERTY OR ADJOINING PROPERTY, r .... J E _ -i........... ...5.... --- i..... .. ...... .. .. - .. ., -. .. - ..-:. ..,,....-L....,. ..: F r DEPARTMENT USE ONLY ApDltenlen Ao ted BY _ D.t. / ATM �•Dt � G—A Infpa tl.n or D.te Pump Infpmtivn By. -- — 1 '] Date D„flnteNen tn.,«ct{en BYI� Date f Getnmesrtf: - ACCOUNTING ONLY: AIDS FAC# �•�Z� PE CODES FEE two AMOUNT REMITTED CHE ASH RECEIVED BY DATE �PERMITIMUMCE REQUEST NUMBER INVOICE l057-6 .u�- II 7 4/ / 3 i i Pub.Health Serv.-En Aro.173(1197)