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SAN JOAQUIN COUNT' PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION j F.G. BOX 988.304 EAST WEBER AVENUE, STOCKTON,CA VA201-SCus €209 468.3420 ICON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i ICemPwte in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERL1IT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIRf D-THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN j JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 311:1$.3 AND TE1E STAI`DARDS OF SAN 1OAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. - IJE JOB AOORERBfOR hPNi�(�L r'1 It d'.1 � (�-S�l( h F-�- CTT" I CyC� ;:�.1 Y�J {. .:� '� PARCEL 91ZE.'AP!7/� �- 1} ! OWNER'S NAME ' c'i '1 P L1 - 1"1- r? - 1 l L�P.LTL)RE66(-47—F@'��L,. ,.(�''� a t Ll=i V�'t r��1 A�`s'l.:v':,PHONE CONTRACTOR Y\ ADDRESS F-•��. SUBCONTRACTOR 1 i72'w. �r P' �� _ _- �''•'� +` AooREsfi L1Ca PHONE TYPE OF WELIJPUMP; M NFW WELT ❑ REPLACEMENT WELL ❑ MONITORING WELL i ❑OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑CRO OSS-CONNEgCT REPAIR ❑VAPOR EXTRACTION -IWELL i J - Naw❑. 11—Ir H.P.�S— DEPTH PUMP 5ET/ , FIRST WATER LEVEL �7 Q TYPE OF PdFAPI ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELLR ❑ BOIL BORING S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A. ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO D ❑ DOMESTICIP NATE �GPAVEL PACKISIZE TYPE OF CASINGISTEEL/PVC f.� DIA.OF WELLCASINO ❑PUBLICIMUN1CIPAi ❑DRIVEN OEPTH OF SPOUT SEAL�' SPECIFICATION I IRRIOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY [/':I j am:.,J�...Ilri_ GROUT BRAND NAME j+,. �- L•� E' ` ❑MONITORING _ GROUT SEAL PUMPED Yee ❑No CONCRETE PEDESTAL BY DRILLER,2�Y. ❑No S_ 1 �� k[F APPROX.DEPTH LOCKING CHESTER BO%IBTOVE PIPE Sl PROPOSED COHSTRUCTIONIDRLLINO METHOD: MUD ROTARY._,AIR ROTARY AUGER CABLF OTHER } i HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANo REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:'r CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERfIFIE� THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERIT SH MIs ISSUED.1 ALL EMPLOY PERSONS SUBJECT TO WORKEN MAN'S COMPeATION LAWS O CALIFORNIA.' E AI1PMICAMT MV TCA 24 Iq VRS!N ADVANCE FOR ALL REQUIRED INSPECTIONeAT{1ZO�Y1461y123. COM"LATE DRAWING AT LOWER AREA PROEO, iL+` TId. S 6-L-! Y Y'� .s� �Oele _? 7 `^ Y PLOT PLAN to,—In&.10SuIe -to 1 1, NAMES OF STREETS OR ROADS NEAREST TO OR nOUNDINO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 7 3,OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AHD NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3.DIMENSIONED OUTUNF,S AND LOCATION OF ALL EXISTING AND PROPOSED E, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ... ... ` ... - �.. . .. .. .. .,..... . L-. ..< .., ... .. ...i .. . 3 .E........ ..-J,. -...,,.E .- E. �,,,.. - :..., - ...... ... ... .,,.... .. .. .... ..,, 1 i� c „ ..,,LSF€ ! ,�. ...... T? I .- I �, � i€�Frll I .YID DEPARTMENT USE ONLYLI.L,�'- APPSce11—Ac wled BY "L 5 Ara 7 ! `1 GION ImPecllon RY -L �._ Dete j(�. Prim9 ineoec[le0 BY I�-�' Oete,S.3 �(� 1 ` Deeeructlen InePecpon BY 9ele I C9mm W ACCOUNTING ONLY: AIOi FAGF PE CODES FEE 1 AMOUNT REMITTED HEC MASH RECEIVED BY DATE PEI4MI7LeElIVLCE REGUEST NUMBER INVOICE