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OWNER'S NAME ill 111 (-41r11 OIL (C1161,113D5E55 6c C, -t-f (1,1 c 14 PHONER C / I <br /> <br />CONTRACTOR CAJ TZgp- it- ADDRESS Z2u (0. 0,10v., cco( tlIc4 65/S0 PHONE <br />SUB CONTRACTOR 10 (O/ ADDRESS ( IN C.-LL LICACS 1 ZI.Cf PHONE 0 116 S-v <br />NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED <br />(Complete in 'Diplimo) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOPIC DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9- 1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNS E.-; 0 I 0 cire PARCEL SIZE/APRS <br />CONSTRUCTION SPECIFICATIONS <br />g ti DIA. OF WELL EXCAVATION <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />'VI OTHER <br />DIA. OF CONDUCTOR CASING <br />DIA, OF WELL CASING <br />SPECIFICATION <br />CONCRETE PEDESTAL BY DRILLER. CI Yr 0 No <br />INTENDED USE <br />0 INDUSTRIAL <br />0 DOMESTIC/PRIVATE <br />0 PUBLIC/MUNICIPAL <br />0 IRRIGATION/AG <br />ONMONITORING <br />APPROX. DEPTH <br />TYPE OF CASING/STEEL/PVC f' V C. <br />DEPTH OF GROUT SEAL is D <br />GROUT SEAL INSTALLED BY (4,-/VIAAJT...q GROUT BRAND NAME <br />GROUT SEAL PUMPED, El Yee VNo <br />LOCKING CHESTER BOX/STOVE-PIPE <br />App/Vs/Ion AccepIed By <br />Grout Impaction By <br />DeettuctIon Inepeollon By <br />Comment.: <br />1714 <br />DEPARTMENT USE ONLY <br /> Dote 7 Arne <br />A <br />.1,•Am <br />Oat Pump Ineper:11on By <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201 388 <br />(209) 468 3420 <br />TYPE OF_EliPUMP: 'NEW WELL 0 REPLACEMENT WELL <br />0 INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR <br />New 0 Repair <br />(TYPE OF PUMP) <br />0 OUT-OF-SERVICE WELL <br />0 DESTRUCTION: <br />0,MONITORING WELT If 3 0 OTHER <br /> <br />0 VAPOR EXTRACTION WELL <br />FIRST WATER LEVEL <br /> <br />0 <br />II tzt SOIL BORING <br /> <br />DEPTH Nov SET FT, <br />0 GEOPHYSICAL WELL I <br />PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER \)‹ CABLE OTHER <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOVIN COUNTY ORDINANCES. STATE LAWS, AND RULES AND REGULATIONS OF THE SAN JOAQUIN couNrv. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S SIGNATURE CERTIFIES THE FOLLOWING:' CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF / CALIFORNIA. THE PPUCANT T\IT CALL 2.4 HOUSIS IN ADVANCE FOR ALL REQLRIIED INSPECTIONS AT 1205I 4553423. COMPLETE DRAWING AT LOWER DA.7.A PROil VID(ED I . 1 , I <br />Signed X ....-... Title <br />PLOT PLAN (Drew to Scale) Scale I - Is L 0 <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. <br />EAST 10 4 '\Tgcci <br />LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS, <br />E. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br /> <br />Li f OttioZ alA.11(- <br />(oso <br /> <br />0 o)V;..n \ <br />ACCOUNTING ONLY: AIDS FAC// <br />-----................."*N8 6'>7791))/7/7-`71,6 <br />PE CODES FEE INFO AMOUNT REMITTED HES,./C ASH RECEIVED BY DATE PERMIT/SER QUEST NUMBER ---- INVCIIGE <br />14 //7 qs-i ,,friftv oov -vis- L.op