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JOAQUIN COUNTY PUBLIC HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISION P.O, BOX 388, 804 EAST WEBER AVENUE, STOCKTON, CA 95201-W (209) 482-3420 11011-REFUNDABLE PERMIT APPLICATION t8 HER(BY MADE TO THE SAN JOAOUIN COUNTY FOR A P'ERAI(T TO CONSTRUCT AND/OR WYTALL THE WOW DESCRIBED.THIS APPLICATION 15 MADE IN COMPt.IANCE WITH SAI JOAOUIN COUNTY DEVELOPMENT 1(TTtE_CHAPTER 9-1 1 15.3 AND THE STANOARO9 OF SAI JOAOUIN COUNTY PVBLIC HEALTH SETiVECES,ENVIRONMENTAL HEALTH DIVIS`IONJ } JOB ADORPS8/0R//A�PNO 2 J -1 �f��: T �� J� 5 CfTY e� �/`" PAACEL BLZE/APNs OWNEPt'e NAMf � � - GI'V`LY�-IC ADDRESS f,1A� /� JJ 1 � _/�_!�/� I�lU7>(.IL /\L L%�1 PHONE• coNTRACToa I j �-Sf�f� I �� •�c�t✓•/ice/��,1�/ c' ! AIL iI.';'ro'�S, c i c-�-t ��yyr —I � ✓ /�''-,/ / ,'�DOREss/a I"l fa,u'-, Ct" -yLics PHONE f SUBCONTRACTOR . r,`y IC PHONE/ f/s Z 3. TYPE Of VVELIJR)MW D NEW"ELL ❑ REPLACEMENT WELL ❑ MoN[TOR/NG YvEu♦ ❑ OTTER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-COWMCT REPAIR ❑ VAPOR EXTRACTION WEU J J ❑N.w❑R.otAr H.P. DEPTH PUMP OCT FT. ARBT WATER LEVEL O (TYPE OF PUMP) (� C3 T-OUT•OF-SERVICE WELL LD GEOPHYSICAL.Wfu f eptl BORING /Vic'Z i US/f B ❑OESTRUCTION: INTEPAOED URL TYPE OF WfU CONITRUCTION APECAT10N6 A ❑ I NOUSTtoAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 01A.OF CONDUCTOR CASING D ❑ DOMESTICi,-VATS ❑GRAVEL PA.cx/BTZE TYPE Of CA8LNGrSTEEIJvvc DIA.OF WELL CA61NG D ❑ PUMIC/MUNICIPAL DRIVEN DEPTH OF GROVT SEAL SPECIFICATION R ❑ IRRiOATIONlAL OT/+ETt OROVT VCAL INSTALLED BY GROUT BRAND NAME E ❑ UOMTORINO `I OROVT sc� PUMPED: ❑Yr ❑N. CONCF-E-E PDES ETAL BY DRILLER:❑Yr ❑No S APPROX.DETTH 2c !� LOCKING CHESTER 5OX/STOVE PIPE S PROPOSm CONSTRUCTION/DRILLING METUOD: MUD KOTATY AEA ROTARY AUGER CABLE OTHER 0/1?Zz/ pV'S/r I HE-CRY CERYWY THAT 1 NAVE PREPARED TH1l+APPUCATtON ANO THAT THE WOFK WRL BE DONE IN ACCORDANCE WITH SAN JOAQLRN COVNTY ORDINANCES,STATE LAWS,AND RULES ANC REOVLATIONII OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED ALIENT'S SIGNATURE CERT"Wa THE FOLLOWINO: -T CERTIFY THAT W THE PERFOP"ANCE OF THE WOAf(FOR WHICH TMs PCP*ArT Is 168UED,1 SHALL NOT EMPLOY PERSONe SUBJECT TO WORIO.IAWS COMPENSATION LAWS OF CALtFORM1_- CO rTRACTOR'v MWNQ OR SUBCONTRA[.'TINO SIGNATURE CEATIFIEF THE FIDUOVANG: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW(FOR WHICH TINe PEVA TT IS IBSUID,1 SHALL,EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Of CALIFORNIA_' /�AA�,fff,��I��'�'�'ANT MVST CALL 2A HOURS IM AbVANcE FOw ALL RfMOKED )"t*P�CT`OMm(AT MIM i/MJa2S. COMPLETE DMVVING AT LOWER AREA PROVIDED. 81pr..d X G L•-r.��•lJ"�-rt'"rT�.� Th1• V �b✓ L�//C-�% I ��G�� PLOT PLAN fprt I•Sc•N•1 Soak 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE P%OKRTY, 4. LOCATION OF HOUSE SEWAGE OISP09AL SYSTEM OR PROPOSED 2. OUTLINE OF THE PRppERTY,GIVING DIMEN870N8 AND NORTH DIRECTION. EXPANSION OF VEWAOE D49PODAL SYSTEMS. 3. DLUENNONED OUTLINFA AND LOCATION OF ALL£XISITNG AND PPOPOSED S. LOCATION OF WELLS NTTHIN RADIUS OF ONE HVND#%ED FIFTY FT. STRUCTURES,INCLUDINO COV'EAED AREAS SUCH AS PATIOS,MVEWAYS,AND WALK8. ON THE PROPERTY OR ADJOIMNV PROPERTY. T7 AP CSN BACK . ................... DEPAXTMQ/T USE ONLY APPNi•.11—Ac Id By �"t��'� O•u L 7 Atm. WeaA w..emue..BY D•t• Pk—P IrM,.et1 By U.t. D..IrVGtI•rt Mr.P.alen B1' ,tom) D.1. ACCOUPMN0 ONLY: AID! FAC, Ps CODES m INFO IJMOUK7 PJWrrTED CNE¢'kl/CASH REc9VEp tY DATE P99kAIT/AEUMCI REQUEST NUMBER INVOICE O/2-