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r ENVIRONMENTAL HEALTH DIVISION i P 0 80!( E,., 445 N. SAN JOAQUIN ST., STOCKTON, CA -J1-388 (209) 468-3420 RON•REFZlNDABLE PEAINIT EXPIRES 1 YEAR FROM DATE ISSUED (complete in Tripliate)I PPPiJCATION 1S HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN OA�Q-UIN COUNTY DEVELOPMENT]TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. OF pDRESS/OR APNI / ef"1 �P�L� Stj ;Yf y� - * CITY ^--I PARCEL SIZEfAPNi WNER'S NAME Cl l d ADDRESS �` PHONE J Of^iACTOF% I et.�,f-- -I�Y71r• L ADDRESSorf y LIC: PHONE s5'1J•3-47'—41 UE.y:JNTRACTOR i r, `i viv1 , -r ADDRESS uCr P,�•00 Z 2.3 I �arK�Iti 7 &17 1 I P4IONE s�� ' 1r� YP.��F WELL/PUMP; NEW WELL ❑ REPLACEMENT WELL I� MONITORING WELL f II- r ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ';❑ CROSS-CONNECT REPT 1R ❑ VAPOR EXTRACTION WELL/' J YPE OF PUMP) 13 Now❑Repair H.A. i�DEPTH PUMP SET FT. FIRST WATER LEVE! O ❑ OUT-0FSLERViCE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING 'l 8 I LTRUCTION: 1 , I I TENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS J FUSTRfAIR ❑OPEN 80TTOM DIA.OF WELL EXCAVATION RIA.OF CONDUCTOR CASING I 'MEMCIPRIVATE GRAVEL PACK/SIZE If t7 II TYPE OF CASINGISTEE'LIPVC ( DIA-OF WILL CASING_ 2 D PUBUCIMUNICIPAL 1:1 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION J ��- F NGATION/AG ©OTHER 1 I R- GROUT SEAL INSTALLED BY_Q 9ak hA� GROUT BRAND NAME , ��,-- l E 1NiTOWNG L/� }� GROUT SEAL PUMPED: ❑Ye.'PW CONCRETE PEDESTAL BY DRILLS FL- Yr ❑Na S �F—X.DEPTH V '^-�'�( LO CKING CHESTER BOX/SITOVE PIPE S. IOP'OSED CON57RUCT1ON/DRILLlNQ METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER IE 3Y CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO 'G_.l4TIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES TILE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH IIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA CONTRACTOR'S miFLNG OR SUB-CDNTRACT7NG SIGNATURE CERTIFIES Il:FOLLOWING: 'f CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT Is IssuED�I SHALL EMPLOY PERSONS SUBJECT To C NTRACuAN'S LNG SIG iAT1RE LAWS OF LL •�RNIA." T PPt,IGANT MUST GALL 24 FLOURS 1N ADVANCE FOR A REQUI SED INSPECTIONS AT(2091441O8-3473. COMPLETE DRAWING AT LOWER AREA PROVIDED, "I' X I •- nue �c=f � 9S i Da[e PLOT PLAIT IDraw to Scale).:Saale "to— f7hES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DOSP05AL SYSTEM OR PROPOSED f -UNE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. i' EXPANSION OF SEWAGE DISPOSAL SYSTEMS. LS WITHIN RADIUS OF ONE HUNDRED FIFTY!T. IENS40NED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY LS ADJOINING PROPERTY, r^. - - - .................. ....... - - ....... .. .. .. .. .. .. -- -• - .. t --- .... ..:.- -..:.......!....-:... ......:............ .. .. .. ....... .. .. ......... .................... .. :......... - J .. .................. ...... ..:.. ... ................:.. -- .. .. :..--..:: .... ..:.. ...... ... :.... :- I .. :... .. _. .............. _....--- :.....--.. l� - J .. �... .. ------------------------- ;. . - . _ .. ._... . ............... : - : 4 II