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APPLICAIIUN tun 99tLLlVUIYr rtKMII <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 388, 446 N. SAN JOAQUIN ST, STOCKTON, C 0201.388 <br /> ( @, 1t1 j L HEA�_Tit (2091468-3420 <br /> FR'1iCE NAI.)l1 <br /> NON.REFUNOAStE PERMIT EXPIRES 1 YEAR FROM OATS ISSUED -7 ;/' <br /> ® II�L [ (Complete is Tnylmatel / <br /> A�Lj �,j d.lJ�s �• e Ib}+'{aaid� �o�ihe San Joaquin County for a permit to construct and/or install the Vorl�)fs��+'ab�ed. This application <br /> made (n Compliance with San Joaquin County Development Title, Chep er 9-1115.3 and the Standards of San JbhY�Ji�9 county Public Meall <br /> Services, Environmental Health Divisio <br /> n �© n10l � 1 <br /> Job Address/or APN# �� Iw���-tom LL l City LalIro C) Parcel Size/APN# <br /> 1 1_ <br /> owners Marne 'S• `C n C Aa 0 Gpligmm6dress S Ar 2A.n4EM o `l>S)9Z.I CT Phone # <br /> Co rucl. PrDI �,QP Address 10391 01A pl MAYAlll # C4)e KOAA Lic# Phone #CQI` 2•' Ss31 <br /> La CA . <br /> Teed, Address 21¢x, 1-lan1ndt% Lic# 723719 Pnone `186•L2$4 <br /> 5 99_79 <br /> d YoSS' Ld�:4k aS 1.2.26$ Phone.i C2 tfM) 65-811AL <br /> 'J- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ REPLACEMENT WEI I U❑ MONITORING WELL Ate—' ❑ OTHER <br /> ❑ DESTRUCTION ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # ❑ SOIL BORING <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR J9 VAPOR EXTRACTION WELL #1_S <br /> ❑ New ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS " n <br /> ❑ INDUSTRIAL ❑ OPEN BOTTOM CIA. OF WELL EXCAVATION S R> to DIA. OF CONDUCTOR CASING (� A <br /> ❑ DOMESTIC/PRIVATE JIB GRAVEL PACK/SIZE 7-11t. TYPE OF CASING/STEEL PVA DIA. OF WELL CASING 2" <br /> ❑ PUBLIC/MUNICIPAL ❑ DRIVEN SANG DEPTH OF GROUT SEAL SPECIFICATION SCN 40 <br /> ❑ IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY $PECIRAH GROUT BRAND NAME (y. Cp"`M"tiy" <br /> g Mp <br /> MONITORING L/Avoe )Ck^tk'en GROUT SEAL PUMPED: 10� Yes ❑ No CONCRETE PEDESTAL BY DRILLER: ,Yes ❑ <br /> APPROX. DEPTH 15 LOCKING CHESTER BOX/STOVE./PIPE <br /> &ROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER /v CABLE_ OTHER_ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinance <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or Licensed agent's signature certifies thefoLLowing: <br /> certify that in the perforaance of the work for which this permit is issued, I shall not employ persons subject toWORKMANIS COMPENSATI <br /> Laws of California." Contractors hiring or subcontracting signature certifies the following: " I certify that in the performan <br /> of the work for which this permit is issued, I shaLL enploy persons subject to WORKMAN'S COMPENSATION Laws of CaLifornia." THEAPPUCA <br /> MUST CALL 24 HOURS IN ADVANC LL FEDUIREO INSPECTIONS AT (209)449.3422. Complete drawing at,Lower area provided. <br /> Title j'I[17„��jHt (P+ti')oc eY Date�,S W <br /> Signed X <br /> PLOT PLAN (Draw to Scale) Scale 1 " to S O f <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or <br /> 2. Outline of the property, giving dimensions and North direction- proposed expansion of sewage disposal systens <br /> 3. Dimensioned outLines and Location of aLl existing and proposed S. Location of wells within radius of 150 ft. c <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. , <br /> PIbE ,=IAA IS VUl 010A <br /> DEPARTMENT USE ONLY <br /> Application �Acgylepted By / ' M Date 0 ' ` if Area < <br /> VUR <br /> `- Date Pump Inspection B Date <br /> Grout Inspection By y1 30 -- <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> jC) 13DES FEE INFO AMOUNT RE EO dtECKAICASH RECEIVED BY DAT PERMITISERVICE REQUEST NUMBER INVOICE <br />