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TIONFOA <br /> �AN JOAQUIN COUNTY P"LIC NEALTN sERY1 <br /> P 0 LOX 3nENYNIOMUNTAL NEALTN a1YJOloiV <br /> ' 446 E, SAN JOAOBIN=T, 3TOCKMX CA "ZO!-M <br /> a00j 4611.3420 <br /> B N <br /> Applicstion is here by made to the San J ba i T�etmf <br /> made ins coeplience with San Joaquin County Development county <br /> far a permit to conatruct <br /> Services, Enyfro�tai Haaith Division, opmeent Title, Chapter 9-1115.3 and the install <br /> tall the work described. This application is <br /> standards of San Joaquin County Public Health <br /> Job Addm'ass/or AINI# S tom,"E; +t78 �.�.�� <br /> City <br /> OwParcel Size/APN# <br /> Owner's Name T Addresa� � <br /> Contractor ' Phone # / <br /> as ��03 ger)_�. WLJC# — Phone #'9SI 'Goi+-Y <br /> �� C011lPOCtOf Address // <br /> '-SFO - <br /> TYPE OF YELL/PIIIP: [I NEW WELL [I REPLACEMENT WELL I] MONITORING WELL 0 [I OTHER <br /> [I DESTRUCTION [I OUT-OF-SERVICE WELL [I GEOPHYSICAL WELL It Efl IIOIL BORING <br /> [I INSTALLATION q WELL SYSTEM REPAIR [I CROSS-CONNECT REPAIR 13 VAPOR EXTRACTION WELL # <br /> [I New [] Repair N.P. DEPTH PLIMP SET T. FIRST MITER LEVEL <br /> (TYPE OF PIMP) <br /> 1111T�USE TYPEOF F WELL CONSTRYCTION NPBMTIM <br /> M <br /> [I INDUSTRIAL [I OPEN BOTTOM DIA. OF WELL EXCAVATION--L`'I asDIA. OF CONDUCTOR CASING <br /> [] DOWSTIC/PRIVATE [I GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA. OF WELL CASING <br /> (I PLMLIC/111MICIPAL [I DRIVEN DEPTH OF GROUT SEAL �'"1� SPECIFICATION <br /> [) IRRIGATION/AG [I OTHER GROUT SEAL INSTALLED BY L .j—� BRAND NAME <br /> El MONITORING GROUT SEAL Pl11PED: [] Yes [I No CONCRETE PEDESTAL BY DRILLER: [] Yes i] No <br /> APPNOX.DEPTH LOCKING CHESTER BOD(/STOVE PIPE <br /> PROPOSED CONSTBUCTIORMNILLNNO METHOD: NW ROTARY_ AIR ROTARY_ AUGER_ CABLE„- OTHER—V— <br /> I <br /> THERV— <br /> I hereby eertify that 1 have prspered this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> State Law-, and Rules and Regulations of the San Joaquin County. Hosie owner or licensed agent's signature certifies the.following: 01 <br /> certify that in the performance of the work for which this permit is issued, I shalt not employ persons subject to-WORKMAN'S COMPENSATION <br /> Laws of California." Contractor's hiring or sub-contrecting signature certifies the following: N I certify that in the psrformenee <br /> of the work for which this parmit is issued, I shall employ persons subject to WORKMAN'S COMPENSATION Lawn of California." THE APPLICANT <br /> TWAT CALL U NOUND IN ADVANCE FOR ALL DENIM INSPECTIONS AT 00 GOB M3. Complete drawing at lower area providad• �r <br /> Signed X Title azo Date:- <br /> PLOT PLAN (Draw to Scale) Scale---­N to <br /> 1. Names of streets or roads nearest to or banding the property. 4. Location of house sewage disposal system or <br /> 2. Outline of the property, giving dimensions and North.direction. proposed expansion of som" disposal systems. <br /> 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> LL:L:L <br /> Jw­ <br /> - ` z <br /> DEPANTMENT USE ONLY <br /> Data y/ ' Area <br /> Application Accepted 1, wzle <br /> Date <br /> Grout Inspection <br /> Date Pup Inspection By By ��– <br /> Destruction Inspection By Data Comments: <br /> ACCOiBXT[NO ONLY: AID# FACO <br /> rE COM FEE INFO AM OiNiITTEO SH NEi ffm BY DATE I'ERM[TISENVICE RMEST 11111111110B NIYBIC <br /> E <br />