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ApPLiK THIN FOR WtLU p PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH$ERV[( . <br /> ENVIRONMENTAL HEALTH DIVISION y� <br /> P 0 BOX 358, 486 N. SAN JOAQUIN ST, STOCKTON, CA 96201.388 <br /> (209) 468.3420 <br /> NOWREfUNDABLE PRINT EXPIRES f YEAR FROM DATE ISSUED <br /> xempiab M Tr4Bnp) <br /> Application is here by wade to the San Joaquin County for a permit to construct and/or'insta(L the work described. This application is <br /> made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> Job Address/or APN# � dq /j,(,ff it y am �'�,1f7�� ( / f <br /> ' " Parcel Size/APV* �a )C�Z7 <br /> Owner's Ne��hM c .W Sell T� Addreas�� W. Jl: ��.. <br /> /�"� ^��. p - Phone *c7Vi� --2?74Contractor Address 1&3 Lice —' Phone aI7 <br /> Sub Contractor y �.�s(e. Address S c rp7� Phone r <br /> romp <br /> TYPE OF FELL/PUMP: 0 NEW WELL 0 REPLACEMENT WELL (] MONITORING WELL P_ [] OTHER <br /> DESTRUCTION 0 OUT-OF-SERVICE WELL (] GEOPHYSICAL WELL 0- 100' 0 SOIL BORING - <br /> (] INSTALLATION 0 WELL SYSTEM REPAIR (] CROSS-CONNECT REPAIR El VAPOR EXTRACTION WELL M <br /> (TYPE OF PUMP) 0New (] Roof H.P. DEPTH POP'SET FT. IRST WATER LEVEL G'� • <br /> Mon USE TYPE OF iMELL CONSTRUCTION SPECIFICATION! <br /> if <br /> (] INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION J► f� DIA. OF CONDUCTOR CASING <br /> a <br /> (] DOMESTIC/PRIVATE Jf GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC 'OV C DIA. OF WELL CASING <br /> (I PUBLIC/MUNICIPAL (] DRIVEN Sf, 04-DEPTH OF GROUT SEAL SPECIFICATION <br /> (] IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME UIQ <br /> fieNONITORING GROUT SEAL PUMPED: 0 Yes 0 No CONCRETE PEDESTAL BY DRILLER: I] Yes 0 No <br /> APPROX D&TH LOCKING CHESTER BOX/STOVE PIPE 1130)el <br /> PROPOSED CONSTRUCTN)N1010LLNG METHOD: MLA ROTARY_ AIR ROTARY_ AUGER_ CABLE_ OTHER_ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: "I <br /> certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or sub-contracting signature certifies the following: " I certify that in the performmnee <br /> of the work for which this permit is issued, 1 shall employ persons subject to WORKMAN'S COMPENSATION Laws of California." TNEAPPLICANT <br /> MST CALL 24 HOURS NI ADVANCE FOR ALL REQUIRED HISPECTIONS AT(206)488.3423. Complete drawing at lower area provided. <br /> Signed X /7�/�r_ Titla^�r+T� CSI7D�A�1 Date <br /> PLOT PLAN (Draw to Scale) Scale " to <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or <br /> _' <br /> efts sAal Norexisting and proposed <br /> direction. proposed siveneien of sewave d spa :"Stems. <br /> 3. ed 5. Location of wells within radia* 64 ISO ft. on <br /> 9#i�ionad outl#ftea sfti 1��on of alt <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> a <br /> �► a <br /> DEPARTEM USE ONLY / Qfe <br /> Application Accepted By Date l ��0 Area Gya <br /> Grout Inspection By Date Pump Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> ACS ONLY: AID# FACO <br /> PE CODES FIM NIFO AMOUNT NEWTTEO CHEC"CASH RECEIVED BY DATE PERMHTIBERI M REOUEST NUMBER NI4M <br /> 3S po1, V 609 —)V 1(–f6 Is -e7 <br />