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JOAQUIN COUNTY DEVEIAP�M/E�NT/TR ,,CHAPTER 9-111 y5...3(A�ND T STANDARD F N JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN# / `� 1/'� MAIM /V//��Vp•�l'1��-}/ CITY�{J��1dACA �( MN �/ PARCEL SIZEJAPN* .v ,OWNER'S NAME /Free^s/^til U ��1/ISL'IM l PA / L/!i -ADDRESS `C'••�l`E'N lWl-�d/��! L�UO A)PHONE# CONTRACTOR ``A `Ic YV r L-I- _ ADDRESS2.02 z E • CMh/ / U�_L' PHONE! — t119 ISUB CONTRACTOR ADDRESS UC# PHONE# TYPE OF WEUJRIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ,/ ❑New❑Flepair H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-OFSERVCE WELLIy{l0 13OEO1Y61CAL WELL) ❑ SOIL BOWNG B 13 ES1VCTION: 17 Vf IUt I,, l -kR 170 /L h ILjU AAD ' QUAISIOIA yn ` A6 0"b7w 1 EINTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS // A INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION OIA.OF CONDUCTOR CASING D DOMESTIC/PRIVATE ❑GRAVEL PACXISIZE TYPE OF CASINGISTEEUPVC DIA.OF WELL CASING O RIBUCWUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E r MONITORING GROUT SEAL PUMPED: ElYr ❑W CONCRETE PECESTAL BY DRILLER:❑Yw ❑No S APRROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTIONIDW WNO METHOD: MUD ROTARY AIR ROTARY AUGEfl CABLE OTHER IIIIIIII i SHEREBY CERTIFY TINS 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND IMULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'i CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOO NMICH THIS PERMIT IS ISSUED.12j4jkNOT EMRAY PER60N8 SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I C IFY I THE RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKNIAN'S COMPENSATION LAWS OF AUFORNIA.' E T {T LL IO IN ADVANCE FOR ALL REQUIRED IN{ ON{A I30{14pJ43i. COMPLETE WIND AT LOWER AREA PROVIDED. IIOeI X -_ Tltle I�� CAPt( t�/E7 t D.t. � PLOT PLAN(Dr.to Sulo)Sulo 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED OUTUNE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. t. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. F� STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. 1, to - !9i u Id ....... ..... PAYMENT ... - - — NOV _7.1995 - - ` ... ._ ..<,.... �..... PUBLIC HEALTH; - ENVIRONMENTALHEALTH llvl� DEPARTMENT USE ONLY o co Z p pplimlon A wtm By Det. rout lrtRwtl.n By Wte Pump Irtiowd.n By Dn. fuwtlon Ir op tlon BY ./�- ,/ mmwer toot 9 &1 ✓ ix