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JOAQUIN COUNTY PUBLIC HEALTH SERVIC/ ENVIRONMENTAL HEALTH DIVISION P.O. BOX W8. 804 EAST WEBER AVENUE, STOCKTON. CA 95201388 (209) 48&3420 W011-REFUNDABLE PERM 1 APPLICATION Is HERE BY MADE TO THE SAW JOAQUIN COUNTY FOR A PERMIT TO CONSTRLICT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAI JOAQUIN COUNTY DEVELOPMENT TTTLE,CHAPTER 9- 99-1115.3 ANMD THE STANOAHD$OF SAN JOAQUIN COIMQTY PUBLIC HEALTH SETNfCE8,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOA All�3 �C3� ' '`4.1— V�'�`t,-e, CITY R\ pO r1\ \_ PARCEL SIZ£IAPw (301 OWTIER'$NAME �Y1 O Y1r1E.Y O� ADORE99 `I�Q00 f�Ac 'f T� I V G� �s~.�' HONE rw r�" �Y'�^�A•h CONTRACTOR— V@,-r s-,y-- .L r,C_ ADDRESS 7'r rn IV 0 r� AV- �rGi� PHONE E 916 SUB CONTRACTOR 1 4c,Y�'I� ADDRS99 — I 1 � — L1Cr—,7 / ' PHONE r _ TYPE Of MP: ❑ NEW WELL LJ REPLACEMENT WELL ❑ MOWTORINO WELL r ❑ oll-v ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROBSCONNECT REPAIR Cl VAPOR EXTRACTION WELL r ❑N•w❑rw'." H.P. DEPTH PUMP BET FT. FIRST WATER LEVEL O (TYPE OF PUMP) -1 ❑ ovr-OF:&EttVICE WELL ❑ GEOPHYSICAL WELL,s -BAIL WMNO a I\A—a r ❑DEBTROCTION: �� \\ INTENDED u!j TYPE OF WELL CONSTRUCTIoN•PECIFiCAT10Nt A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OP CONDUCTOR CASINO D ❑ DOMESTICIMVATE ❑❑GRAVEL PACK/92E TYPE OF CA9IN0l8TEEUPVC^� GIA,OF WtIl CASINO O ❑ P MMIMUNICIPAL Cl DRIVEN DEPTH OF GROUT SEAL �.� SPECIFICATION '_ RRA ❑ IMOATION/AG ❑OTHEn GROUT SEAL INSTALLED BY GROUT BRAND NAME 13 -T7 MONITORING (y� UROUT SEAL PUMPED: ❑Yr ❑No CONCRETE PEDESTAL BY DRILLER:0 Y. ❑No S APPROX,DUITH — 1 e'�� LOCKING CHESTER BOX/STOVE PIPE ( S PROPOSED CONLTRUI4 CTIONtbAsLONO METOD: MUD ROTARY MR ROTARY AVOER CABLE OTHER k0.T\o1 — 0.L4. �(— I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATtON AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAocnN COUNTY ORDINANCES,STATE IAWe,ANO RULES ANL REOVLATION$OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LJCENOED AOENT'8 SIGNATURE CERTIHE9 THE FOLLOWING:-I CERTIFY THAT IN THE PERFOAMANCE OF THE WOW FOR WHIC/ THIS PERMIT 18 ISSUED,1 @HALL NOT EMPLOY PERSONS SUBJECT TO WORIOMAN't COMPENSAIlOP1 LAWS OF CAUFORInX- CONTRACTOR-$HIRING OR SUB-CONTRACTING SIGNATURE CERTIFlEt THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PEFYrrr IS ISSUED,I SHAD.EMPLOY PERSONS SUBJECT TO WORKMAN'S/COMPSNOATION LAWS Of CALIFORNIA-'' TTHE ArAArnXANT MUST CALL 24 HOURS IM ADVFOR FM0001 D INGPIPCTIIIONR At 9201"4".7422. COMPETE LDRAWING AT LOWER AREA PROVIDED. � %rt d XTNI. off �CG`0� VG-f-SA�" 1'`C D■t. G6 - PLOT PLAN Meow 1.Bc.I.I Sod• 'to I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, {. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PTIOPERTY,OMHO DIIACHSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 7. DIMENNOkM OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN FADWS OF ONE HUNDRED FIFTY FT.- OTPIVCTVRES.INCLUDING COVERED AREAS SUCH AS PATIOS,DNVEwAY8,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. wAP BACK . . 1 r DEPARTMENT USE ONLY APPIIWtIpn A.a•Pted By D•t• / A/h A,r u'—t I—.-0—By Doi. Pt—P Irrp.•t1.n Oy b.t. Ge•IruGtl.n In•P.oti•n By D.t. Comm«.t•: ACCOUNTING ONLY: MDR FACT ►[CODES FTE INFO AMOUNT Pm AITTED HE MAiH RECEIVED BY DATE FERIMT140VACE REOUEET MUMMER INVOICE