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^I rLjwr.miV • Pun ■r LLLIrwk%&r rr-nHrIN , v <br /> SAN JOAQUIN CONTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAOUIN ST, STOCKTON, CA 96201-388 <br /> (209) 466.3420 <br /> NON REFUNDABLE PERMIT "PiRES 1 YEAR FROM DATE ISSUED TH1 <br /> {Compbta In TripPuatal <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED THIS APPLICATION IS MADE IN COMPLIANCE WTTTI SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11 15 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION <br /> JOB ADDMS=R APA* 1876 Country Club Blvd. CITY Stockton, PARCEL SMAR40ia—e/123-F�191-01 <br /> OWNERS NAME_ Mr—r&+�YMr���rs..��TMC�aannuel,Sanchez AQDRESS .-1633 Wulnut Street West PHONE, (209) 464-1291 <br /> CONTRACTOR � G83— 1'1�.itvL'r F6 ADDRESS 13% E. Bim' Street LIC* <br /> ri <br /> y� � �r668-1:3PHONE* � OOD � <br /> SUB CONTRACTOR � � cO- ADDRESS P-0- PW�^ p Rl� C� Vl S�� LICS CF7 71NE <br /> TYPE OF WE6 MMP• ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL* ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR CI VAPOR EXTRACTION WELL D J <br /> ❑New I]Repelr H P DEPTH PUMP SET FT FIRST WATER LEVEL p <br /> (TYPE OF PUMP) �.L <br /> ❑ our-OF-SERVICE WELL El GEOPHYSICAL WELL 0 ® SOIL BORING W1th oolleCtIM g <br /> 11 DESTRUCTION of WatEr files by by 2 B <br /> WENDED USE TYPE OF WELL CONSTRUCTION 4.MtRCATIONS A <br /> :I INDUSTRIAL ❑OPEN BOTTOM DLA OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D <br /> LJ I]OMESTIClPRIVATE ❑GRAVEL PACKlSQE TYPE OF CASINGIST1 EUPVC DIA.OF WELL CASING D <br /> Cl PUBLIC/MUNICIPAL 1:1 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> `3 IRRIGATIONIAG ElOTHER GROUT SEAL INSTALLED NY GROUT BRAND NAME E <br /> 13 MONFTORING ''n F+1_ GROUT SEAL PUMPED ❑Y® ❑Ne CONCRETE PEDESTAL BY DRILLER.❑Y. C3 N. S <br /> APPROX.DEPTH 4o 1 t'• LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTIOWDRILLING METHOD MUD ROTARY AIR ROTARY AUGER x CABLE OTHER <br /> _,Ugr;BY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL,R£DONEE 1N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES STATE LAWS AND RULES AIlO <br /> S <br /> CATIONS OF THE SAN JOAQUIN COUNTY HOME OWNER OR LICENSED AGENT SIGNATURE CERTIFIES THE FOLLOWl 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> EH <br /> PERMIT IS ISSUED I SHALL NOT EMPLOY PERSONS SUBJECT TO W W"AN 8 COMPENSATION LAWS OF CAUFORNUI.' CONTRACTOR S HIRING OR SUBCONTRACTING SIGNATURE CERTIRES <br /> FOLLOWING 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN i COIMPE SATION LAWS OF <br /> CALIFORNIA.' THE APPLI T 24 INOUR$IN ADVANCE FOR ALL REOUIRIED INSPECMNG AT 12091 408-3423 COMPLETE DRAWING AT LOWER AREA PROVIOE <br /> oipned X Tlde._ <br /> PLOT PLAN i0rrw to SaeW Sodc 'to <br /> i NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY 4 LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2 OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH 01RECTiON EXPANSION OF SEWAGE DISPOSAL SYGTBW <br /> 3 DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED LL LOCATION OF WELLS WITHIN RADNS OF ONE HUNDRED FIFTY,FT <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS AND WALKS ON THE PROPERTY OR ADJOINING PROPERTY <br /> M,4f W <br /> _ w <br /> DEPARTMENT USE ONLY Dao .? <br /> Application Acacpmd By <br /> ateut Inspectlon BY Deto Pump Iropect6m Br Deto <br /> 3cttnmden Inspection BY "'` Date <br /> --OmMlartti <br /> CCOVNTING ONLY AID* FAC* <br /> PE CODES FEE INFO AMOUNT REYDTTED CHEDK*ICASH RECEVm BY DATE PERM[TISERVICE REQUEST NUMBER INVOICE <br /> 5'0 <br />