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Application Accepted By <br />Grout Inspection By <br />Date <br />Date Pump Inspection By <br />DEPARTMENT USE ONLY <br />Atirieftriri7011 MR JR!WPM r'LlfRR'i <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 Bu _ JIM, 445 N. SAN JOAQUIN ST., STOCKTON, CA 01.388 <br />(209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete in Triplicate) <br />APPLJCATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPUANCE WITH SAN <br />JOAQUIN 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 APN# 6,42_ I ?kctc._e_... CITY <br /> ADDRESS <br />. C>Q1Zi a. <br />CONTRACTOR <br />SUB CONTRACTOR <br /> k.1 <br />OWNER'S NAME NAME <br />L rc-1 <br /> <br />PARCEL SIZEJAPN* <br />PHONE <br />‘157-. (). 2-Az <br /> -7.6DDRESS UCO PHONE * <br />ADDRESS 2.B z. . Li rk-i PHONE 46, ska-it. <br />TYPE OF WELL/PUMP: 0 NEW WELL 0 REPLACEMENT WELL <br /> <br />10. MONfTORING WELLS <br /> <br />O OTHER <br /> <br />0 INSTALLATION 0 WELL SYSTEM REPAIR <br /> <br />0 CROSS-CONNECT REPAIR <br /> <br />O VAPOR EXTRACTION WELL I_ <br /> <br />0 New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br />(TYPE OF PUMP) <br />0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELLS 0 SOIL BORING <br />DU DESTRUCTION: -k-c r ;IT) C.)-6 aCitC r VA (..k.STi <br />TYPE OF WELL <br />0 OPEN BOTTOM <br />0 GRAVEL PACK/SIZE <br />0 DRIVEN <br />0 OTHER <br />INTENDED USE <br />INDUSTRIAL <br />DOMESTIC/PRIVATE <br />0 PUBUCIMUNICIPAL <br />IRRIGATION/AG <br />MONITORING <br />APPROX. DEPTH <br />CONSTRUCTION SPECIFICATIONS A <br />DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING P <br />D <br />TYPE OF CASING/STEE 0 DIA. OF WELL CASING D <br />DEPTH OF GROUT SEAL 9 -cA-- SPECIFICATION R <br />GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br />GROUT SEAL PUMPED: 0 Yee 0 No CONCRETE PEDESTAL BY DRILLER: 0 Yee 0 No SON. <br />LOCKING CHESTER BOX/STOVE PIPE s <br />PROPOSED 1II1D LUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Prcss,-,-:--c tk) <br />..osas <br />I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK NALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LJCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: I CERTIFY THAT IN THE PERFORMANC OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA. T CANT MUSY CALL. 24 HOURS VANCE FOR ALL REQUIRED INSPECTIONS AT 1209) 4418.3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />41 _43 rc Title Pra,Te-k C'tc ate 1Z.5 I <br />PLOT PLAN (Draw to Scale) Scale to <br />OUTUNE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. <br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />ON THE PROPERTY OR ADJOINING PROPERTY. <br />DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS, AND WALKS. <br />411, <br />Sioned X <br />7-q5 Arse 61* ? <br />Date <br />Destruction Impaction By <br />Comments: /- 0c 44.0-4-c <br />Date <br />ACCOUNTING ONLY: AIDS FACir E( -s'i%/-1)_4"-M Y- ) <br />LE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST N INVOICE <br />— <br />351)7, la 60 .0