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SAN JDAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION n <br /> P,O, BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 9520 _88 <br /> 1208 468-3424 C <br /> ICBM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ICBmpIEtE In Tr41'IeEgl <br /> APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CDNSTFIUCT ANDIOR INSTAl1.THE WORK DESCRIBED.THIS APPLICATION 1S MADE IN COMPLIANCE WrTH 9 <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.11 15.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DtTAslok. <br /> ORE8S70R APNf _ <br /> JOB ADCIN �j C <br />' PARCEL 9IIE1AVNf (^ <br /> OWNER'S NAMEWn <br /> f ADDRESS 4�mPHONE f S^ x^17[' <br /> CONTRACTORf I�1` EI e C rT J4 12 , ADORESBp _t 6, of „LACI` 539 a pNOHE t� 'oS.a_ <br /> SUS CONTRACTOR '^ 1 ADDRESS lrCe ^ PHONE a ~� <br /> TYPE OF WELLIPUMP: I❑Y L.ANEW WELL El REPLACEMENT WELL 11MONRORma WELL f 0 OTHER <br /> CRN8TALTIOII Q WELL SYSTEM REPAIR ❑CRO88-CONNECT REPAIR ❑VhPOR EXTRACTION WELL <br /> 1-e <br /> LJ NON 0 P—I, H.P. _ DEPTH RUMP SET FT. FIRST WATER LEVEL y 1 <br /> rrYiEDEPVMP <br /> R�yJ/-G�rn�n/ <br /> J'-i ❑OUFVI <br /> T�OSERCE WELL ❑GEOPHYSICAL WELL I iJ SOI!AOTVN6 <br /> ❑OERTRVCTION: t <br /> a INTENDED VIE TYPE OF WELL CONSTRIL IGH SPECIFICATION• <br /> 17 INDUSTRIAL ❑OPEN bOTTGM DIA.OF WELL EXCAVATION DW OF CONDUCTOR CASINO <br /> ❑DDOMEBTIGRiIVATE ❑GRAVEL PACKISIZE TYPE Of CASING187EELIPVC GIA.OF WELL CASING <br /> L'J PUBLICT.IUNICIPAL ❑DRIVEN OEMH OF GROUT SEAL SPECIFICATION ! <br /> ❑MFdOATIONIAG ©OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME <br /> ❑MONTTORING GROUT SEAL PVMPED:❑Ver [IN. CONCRETE PEDESTAL BY DRILLER:❑Yw ON. ! ; <br /> APPROX.DEPTH LOCKING CHESTER BO%!STOVE F1PE J <br /> PROPOSED CONSTRUCTTOM/ORILUNO METHOO:MUD P.OTARY AIR ROTARY AVGFR CABLE OTHER <br /> y - I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCOROAHCE WITH BAN JOAQUIN COUNW ORDINANCES,STATE LAWS,AND RULES Al <br /> REGULATIONS OF THE SAN JOAOVIN COUNTY, HOME OWNER OR LICENSED AGENT'S STGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF TRE WOfK FOR WHIZ <br /> THIS PERMIT 1019SUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENIATIDN LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR BVS{ONTRACTINO 9sGNATURE CERTIFI <br /> THE FCLIOWING''':���TTT I CERTIFY THAT IN THE PERFORMANCE of THE WORK FOR WHICH THIS PERMIT IB ISSUED,18HALL EMPLOY PERBONB SUBJECT TD WORKMAN'S COMMSATFON LAWS <br /> CAUFORNlA.' T/IfJ A►KICANT MUtT LL 7.lg URa IN AO�ANCE FUR ALL 111131 INs n7TO}nIMS AT r 1 MS.aS��2/!1/J7�CO,LMRF,,TE yDRAWViO AT LOWER AREA PROVIDEO, /`T �7y/y <br /> Blind% /�/ TIIIe_. gJ{ I --iL�T-+CL� � D.t._ �!..J — Y!/7 <br /> KOT PLAN ID—1n S1.1 Sul. La <br /> 1,NAMES OF BTREETS OR ROADS NEARE8T TO OR BOUNDING THE PROPERTY. L.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> Z.OUTLINE OF THE PROPERTY,131WNO DIMENBIOHS AND NORTH DIRECTION. EXPANSEON OF SEWAGE DISPO SAI SYSTEMS. <br /> 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXPS-TI14G AND PROPOSED B.LOCATION OF WELLS WITHIN PI OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES, OUTLINES <br /> COVEREO AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br />[ti <br /> 7tr4T1°r. .Park <br /> r s rn�1 n <br /> �: ... <br /> r <br /> t s... <br /> } <br /> + . <br /> s <br /> Q 7 <br /> ........ <br /> C7... - ',... .. '., �... <br /> fi... �t1N fi Z <br /> a <br /> I:JIfv CE UIr v <br /> . ........:, i i 1 +9ERR11C <br /> ... <br /> n <br /> �. . <br /> .. ... .... .. .,.r ..... .,. <br /> L <br /> OWMTfi}ENT USE ONLY ' <br /> AP011e.ebn A--w d BY -z A,- <br /> Grine"p.atH.BY D.L. P mP Iro mere B <br /> P <br /> D«rrwebn 1n.Pmtron 0Y D.Ia <br /> Cemmmer. <br /> ACCOUNTTN.ONLY: AIDE FAC! <br /> PE CODES FEE AMOUNT REMITTEDHEC //CASH RECEIVED BY DATE MWAITIZERVICE REQUEST NtRABER INVGfCF <br /> t_� <br />