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I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS. AND RULES AND <br />REGULATIONS OF THE SAN .JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOFIC FOR WHICIt <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. • CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES,..2 <br />RMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />URS IN ADVANCE FOR ALL REQUIRED ISISPECTIO II AT 12061 4693423, COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />Slonorl X <br />PLOT PLAN Prow to Fkil.:Soolo to <br />I. NAMES or STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <br />T. OUTLINE OF THE PROPERTY. ammo DIMENSIONS AND NORTH DIRECTION, <br />3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED <br />STRUCTURES. INCIUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WAUCS. <br />THE FOI I OWING: I CERTIFY THAT IN THE PE <br />CALIFORNIA.' APPUCANT M ST CALL <br />) r he Li.0,C.141-4e1) Dwe 9c5 \)•) <br />c tt p <br />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 />1.,dqki? <br />Date -2—t- <br /> <br />At.. <br />Dote C. 2-1( ‘InIct Impaction By D•te <br />Application Accopterl By <br /> <br />VISA AAA ei;4••'\ <br />Grout IntpootIon By AA.A. c La•N <br />APPLICATION FOR WELL/PUMP PER 'k <br />SA. JAOUIN COUNTY PUBLIC HEALTH SE. ICES <br />ENVIRONMENTAL HEALTH DIVISION <br /> 005•(0-.$) <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NOWREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Complete In Triplicate) <br />APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT 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 DIVISION. <br />JOB ADDRESS/OR APN* 503 V.A51" TENTH STREET <br />OWNER'S NAME COVNr1 OF SAN TCAOtiN <br />CONTRACTOR V1-W D i 4 J ADDRESS p c t;c4k 5 1 uciliO 9 CI PHONES 101, '3fil • <br />SUB CONTRACTOR ADD/1E88 <br />13,1C -94511 IJC* PHONE * <br />1S-1.5 <br />TYPE OF WELL/PUMP: 12I/NEW WELL <br /> O REPLACEMENT WELL <br />MONITORING WELLS idloi -1, 3 <br /> <br />O OTHER <br /> <br />0 INSTALLATION <br /> 0 WELL SYSTEM REPAIR <br /> 0 CROSS-CONNECT REPAIR <br /> O VAPOR EXTRACTION WELL I <br />0 New 0 Repair DEPTH PUMP SET FT. FIRST WATER LEVEL <br />(TYPE OF Pt/MN <br />O OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL I 0 SOIL BORING <br />0 DESTRUCTION: <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br />TR A C•(• CITY PARCEL SIZE/APN* I 9- p <br />212. inithvt- Ava„ (Ii FIr <br />ADDRESS 54-er t; tt)vi A 9 5 2 • NIONESI G9 '4 6e ."11 V <br />0 OPEN BOTTOM <br />rirGRAVEL PACK/SIZE 3 Stiod, <br />0 DRIVEN <br />0 OTHER <br />El INDUSTRIAL <br />DOMESTIC/TITIVATE <br />PUBLIC/MUNICIPAL <br />EliIRRIGATION/A0 <br />ler, MONITORING <br />APPROX. DEPTH <br />DIA. OF WELL EXCAVATION e-Anch <br />TYPE OF CASINO/STEEL/PVC <br /> P C. <br />DEPTH OF GROUT SEAL <br /> <br />4- fee't <br />GROUT SEAL INSTALLED BY 'r - <br />GROUT SEAL PUMPED: D V.. WrNe <br />DIA. OF CONDUCTOR CASINO NA <br />DIA. OF WELL CASING ,2. .-1‘ 6 <br />SPECIFICATION Sc It:f <br />GROUT BRAND NAME I'll .r tvoifr E <br />CONCRETE PEDESTAL BY DRILLER: 0 Yon la;lo <br />2.0 feel' <br />LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTION/DR/LUNG METHOD: MUD ROTARY AIR ROTARY AUGER X <br /> <br />CABLE OTHER <br />DEPARTMENT USE ONLY <br />DoyouctIon Inspection By <br />Cronment•: <br />ACCOUNTING ONLY: AIDS FAC// <br />[PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PEFUVIIT/SERVICE REQUEST NUMBEFI INVOICE <br />351D 5f1 r 00 _it 1:2-1 K O-1............ _ <br />.5(2.0D / 73.S---,----="'T <br />Pub. Health Serv. - Enviro. 173 (1/97)