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AprL t.n :v4 ruR iVELL,pU(vlP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SEOmts <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. 80X Sri.,, 344 FAST WEBER AVENUE, STOCKTON, CA 95201388 <br /> 1209) 408.3420 <br /> MON•AEfUNUAdLE PERMIT UPIAES I '1EAIt <br /> ROM.DATE ISSUED <br /> t'amplate III APPLICATION 13 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCTS <br /> AND OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DRRS1pN. <br /> JOB ADDRESSOR APNfyC �p��/' L <br /> /D / CITY p�R,C1[�Jg1�/ <br /> OWNER'S NAME ��C/t:'•'�Id ` Q� ' "� ��� q 7Z3 <br /> VA <br /> ADDRES6 r7Z�AS, PHONE f _ <br /> CONTRACTOR �r rl/`LFj/Ob�, �7t !�}'�'Y1'-�-3 / <br /> f. ADORES6 Irl A-V%alL//1 f/�n LIc / PHONE R <br /> SUS CONTRACTOR r r ADDRESS <br /> t li Lice PHONE f <br /> U, <br /> TYPE OF WELIJPUMR: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ mowromNO WELL R ❑ OTHER <br /> ❑ ❑P..,,INSTALLATIONH.P.❑ WELL SYSTEM REPAIR 1:1 CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> TYPE 0� f PUMP) 13 N. DEPTf1 PUMP SET FT, FIRST WATER LEVEL <br /> DESTRUCTION- ❑ OU -0 <br /> TF-SERVICE WELL ❑ GEOPHYSICAL WELL I 0-15 1L BORING /`r f <br /> 8 <br /> INTENDED ULE TYPE OF WE11 CONSTRUCTION iPECIFICATIONS r <br /> ❑ INOUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION _\ f k DIA.OF CONDUCTOR CASING A <br /> 11DOMESTICIPR IVATE 13 GRAVEL PACK/SIZE D <br /> TYPE OF CASINGrSTEELIPVC DIA.OF WELL CASING <br /> ❑ PUBl1ClMUNICIPAL 13 DRIVEN DEPTH OF GROUT SEAL — v <br /> 11IRRIGATIONG E r SPECIFICATION R <br /> ❑OTHER GROUT SEAL INSTALLED BY L Y^ GROUT BRAND NAMAt <br /> ❑ MONTORNE <br /> GROUT SEAL PUMPED: ❑Yee N CONCRETE PEOESTAL RY DRILLER:❑Yr ❑N. S <br /> APPROX.X.DEPTH LOCKING CHESTER BOXl6TOVE PIPE <br /> PROPOSED CONSTRUCTIONIDMLUNG METHOD: MUD ROTARY AIR ROTARY AUGER S 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 ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAGUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•t CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHPCH <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR Su"ONTAACTING SIGNATURE CERTIRES <br /> THE FOLLOWING: 'I CERTIFY THAT 1N T'HE PERFORMANr r:OF TH£WORC FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN•i COMMSATION LAWS OF <br /> CALIFORNIA.• =APPUC T MUST CALL 23µptiRS�N'k0V 4i:ZZ i0rt ALS AceJ AAED RG&I'lC rIONe nT 12")+dS-:I COMPLETE DRAWING AT LOWER AREA PROM QED, <br /> Signed Trn. ST'K CDL 4q.� L <br /> 3� 9 <br /> PLOT PLAN fDraw to SeW.l Seale 'to <br /> 1. NAMES OF HTREFTS OR ROA08 NEAREST TO OR 80UNOING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED. <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PFOPOSEO S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Fr. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PrgPERTY. <br /> 6I/1,i�l� DEPARTMENT USE ONLY Q <br /> Appl,oation Accepted BY '"`— Date Mr LO/ 1J✓Lt <br /> Grout lrnpeotlon BY Date Ptano lnsoeetlon BY Onto <br /> Dwruetlen Inepeetlen BY ,. Q - Data <br /> Comments' A OW- <br /> ACCOUNTING ONLY: AIOf FAC# <br /> PE CODES FEE INFO AMOUNT R001ITTED C-eqf <br /> ASH RECEIVED BY DATE PERMIT/49MCE REGUEST NUl1MS6U INVOICE <br />