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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMENT ENVIRONMENTAL HEALTH DIVISION RECEIVED P 0 BO,.:s88, U5 N. SAN JOAQUIN S1., STOCKTON, CA 101.388 (209) 468-3420 FEB 15 1996 NON-REFUNDABLE PERMIT EXPIRES 1 ERR FROM DATE ISSUED SAN JC'---jU1N COUNTY PUBLIC HEALTH SERVICES IONS RUClats in AND/OR taI ENVIRONMENTAL HEALTH DIVISION APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT 70 CONSTRUCT AND10 INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER .9-�1�11 5.3 AND THE STANDARDS OF SAN JOAQUIN COU7PU8IJC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOS ADORESSIOR APN# V�.� 'I� CITY PARCEL fS�,QF�JAPNN OWNER'S NAME O� \L1 ADDRESS Tj LJ,(`tT-%ta O � $ . CONTRACTOR `\ ADDRESS M,I4# PHONE SUBCONTRACTOR N ADDRESS IIC �nL -tS PHONE TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MoNTTORING WELL Y ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑ CTYPE OF PUMP) New ElRepelr H_P, DEPTH PUMP SET FT. FIRST WATER LEVEL O pp�� 11OUT-0F-SERVICE WELL�� 13 GEOPHYSICAL LL# 11 SOIL BORING g MDESTRUCTtON: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION IA ❑ INDUSTRIAL 13 OPEN BOTTOM DIA.OF WELL EXCAVATION �I DIA.OF CONDUCTOR CASING p tI DOMESTIClPRIVATE ❑GRAVEL PACK/812E TYPE OF CASING/STEEL/PVC_jt DIA.OF WELL CASING Z. _ _ p ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME (4wv0 r+ E -❑ MONITORING GROUT SEAL PUMPED: ❑Yee ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Ya ❑Na S APPROX.DEPTH LOCKING CHESTER BOXtSTOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN AC CORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"1 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 SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WQFWWA)d'S COMPENSAITON LAWS OF CALIFORNIA.' THE APPLICANT M 7 CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120914683423. COMPLETE DRAWING AT LOWER AREA PROVIDED, Signed X V Title Daro PLOT PLAN{Drew to Scolel Seale to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WTT1iIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. DEPARTMENT USE ONI Y / f� Application Accepted BY a��, Deta 2- -7--/"' Arae Grout Inspection By Date Pump Inspectlon By I n Date beetruction Inspection By / 64 G f Commente:e-TAl W jL.[,YJ.c.a.gt� �• .., r ACCOUNTING ONLY: MIO# FAC# PE CODES FEE INFO AMOUNT REMITTED HEC /CASH RECEIVED BY O TE PEII6MIT1B13TVICE REQUEST NUMBER INVOICE