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r PAYMENT SARI JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION! AUG 1 2 1997 P.O. BOX 388, 304 EAST WESER AVENLH,STOCKTON, CA 95201388 (2091 488.3420 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES NON-REIPMABLE PERMIT 4,{ ENVIRONMENTAL HEALTH DIVISION APPLICATION IS HERE BY MADE TO THE SAN JOAOVIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL.THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WTTHt SAN JOAOUON COUNTY DEVELOPMENT TITLE.CHAPTER 9-11 15.3 AND THE STANOARDS OF EMI JOAQUIN COCUNTY PUB1LICy HEALTH GVROCES,EHVMONW`NTAL HEALTH OMSION. (� � JOB ADDRESSOR APN& "A 1� 4 E• ' q 111 S Tr-t�'`� CTry 7)0( 10 F D o Q 1 PARCEL sIZvAPwI ��t v F OWNER'S NAME 90-\,/ H O Y/s a ll _ A.11.6046`40 IV •. TJa L.'{1 S 1"�CA .( 5 r�I 0 PONE CONTRACTOR Ilyo'gtt ra � N pYI HNlapt d� �I1 f- ADDRESS 1402 W. MgpcL q01 I PFIONE&gSV-0;61 SUS CONTRACTOR ADDRESS UC& PHONE& TYPE OF WaIA-IMh: ❑ New WELL ❑ NSEPLACEMENT WELL ❑ MOMTORNo WELL& ❑ OTHER ❑ RtSTALLATDON ❑ WELL SYSTEM REPAIR ❑ cRQs6coNNEcT REPANS E1 VAPOR EXTRACTION WELL I J ❑Naw❑F.,w, H.P. DEPTH PUMP WT FT. FIRST WATER LEVEL O ITYPE OF PUMP) ❑ Otmor-ceRVPCE WELL Q OEORtYSICAL WELL SOIL SO 1ONO S ❑DESTRUCTION: INTENDED LISE TYPE OF WELL CONE UCTON SPEcowATIO ,t A E1 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CA84NG ' D ❑ oomESTICJPRVATE ❑GRAVEL PACKIs1ZE TYPE OF CAs1NO/STEEI/PVC IMA.OF WELL CASINO D 13 IVSLICIMUNICIPAL ©DMVEN DEPTH OF GROUT!REAL T.p SPECIFICATION p y' R EI IRYGATTON/AO ❑OTHER GROUT SEAL..INSTALLED BY OROLIT BRAND NAME1 OYi Id Vc) (3µ).14U E 13 t.NoNITDRNNO GROUT SEAL PUMPED:❑Y. lame CONCRETE PEDESTAL EY DUUIUEPC❑Yr (9No s APP"X.D*FTH LOCKOM CHESTER SO XISTOVE PIPE y n S PROPOSED CONiTRVCTFON/DWILIMO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER CkIiN G! pale 1 HE4EkY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WTTH SAN JOAOWN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR UCENSED^QfNT'S SIONATURE CERTIFIES THE FOLLOWING:7 CERTIFY THAT IN THE PffiORMANCE OF THE WORK FOR WINICH THIS PEAMTT tS ISSUED,1 SHALL NOT EMPLOY PERSONS MAMCT TO WORPOAMYS COMPOISATTON LAWS OF CALIFORNIA.' CONTRACTOR'S HJW40 OR SM-CO)STRACTRNG MONA. CERTIFIES THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT UB ISSUED,i SHALL EMPLOY PERSONS SU&MCT TO WOROW"G COMIYNSAYMN LAWS OF CAUFOR IA."NTTH,E�A�PPLIC�AT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQURED MOPCCTgNO AT1It"S))4440*423. COMPLETE PRAWR O AT LOWER AREA PQR�O D VIOE2. [� 54—d X2✓lr'YU •y//"4 ' —D PLOT PLAN IO—to t-Ao sc.l• to t. NAMES OF STREETS OR ROAOS NEAP418T TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYHTEM 015 PROPOSED 2. OUTLINE OF THE PROP EPtTY,UNW40 DOAEHMNS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIHPOBAL SYSTEMS. 7. DILKNOfONED OUTLINES ANO LOCATION OF ALL EXIVnNO AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTVSES,INCLUDWO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPEKTY OR ADJO"NO PROPERTY. ....... MAP CSN BACK ..... .............I............I... .. ..e.. . ..i... ................................... ...... ...... .................. ................................. ........................................ DEPARTMENT USE ONLY ^—�� 7 APpiNpetRotf Aoogtad DY Date `aJ M.r 6':R- 01"t—peC0—6Y Date P—w tnapaction BT Ota p..vuctbn kweO�+SY �y Data ACCOUNTWO ONLY: ANDS FAC& PE CODE2 FEE I?" AMOLMT Ptg6cmm CHECK&ICASH RECEIVED ItY DATE PEWIRISERYICE REQUEST MUMMER A7NOICE 3501 �i�