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FACS AIDS ACCOUNTING ONLY: <br />DEPARTMENT USE ONLY <br />Application Accepted By (--.C2et <br />,, (uout Inspection Sy cf" Putop Inspection By Dete <br />Onentiction inspection By <br />Corornentv .cc.crz...ei xt 7c, ck axe „,,c41- s y <br />Date //-1 Artio 0/ <br />Date <br />I 14.4-jt, FULL DiSKLISLAS <br />CROUP/ MAL OUu LI ,,LL, <br />WA. <br />SST • SOA SOILING LOCAL. <br />PROPOSES ILLOLAILJANS KU LOCAL,. <br />FisLALA Miro...RI Oat rfatileAlco <br />Loyv .oustal <br />w <br />SITE MAP <br />SCALE IN FEET 1.-20. <br />Pub Health Serv. - Enviro. 173 (1/97) <br />PE CODES FEE INFO AMOUNT REMITTED 1C110//CASH RECEIVED BY DATE PEPPAIT/SERVICE REQUEST NUMBER INVOICE <br />3-.-5-0/ <br />_ Fcr — .91-00 ‘-' (2-'0 42- Ii (G kr- 7 0 f <br />__ SCkO_ b VI_ cil 2. <br />TYPE OF WELL/PUMP: gt NEW WELL (3) <br />0 INSTALLATION <br />0 New 0 Repeir <br />(TYPE OF PUMPI <br />cos e <br />APPLICATION FOR WELL/PUMP PERMIT <br />SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />11011•REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />JOAOUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />AppucATion IS HERE BY MADE T() THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE VVOFK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br />(Complets In Triplicate, <br />JOB ADDRESS/OR APP/I/ C -2 12 E 11A <br />tt E (211-2-CA-•A-Q OWNER'S NAME Lo <br />CONTRACTOR ArrL aSS CA•C+.1- 'CS • I *Art <br />SUB CONTRACTOR V S; D rO tt 'l <br /> <br />CITY SIMS-L.1-cl PARCEL SIZEJAPNS <br />ADDRESS 10. • A r C. 41-Ci 0-41-1 1411 PHONES 6.7-- 6- <br />ADDRESS 12.4 6 ("‘" UCI? PHONE # 1-'29 ""•2., Z.Z.1 <br />ADDRESS O 1110,X (1.-10 V utics -12490 II PHONE /1-0.7.1..?q• <br /> <br />REPLACEMENT WELL <br />0 WELL SYSTEM REPAIR <br />egf MONITORING WELLS I - 3 0 OTHER <br />0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELLS <br />DEPTH PUMP SET FT. FIRST WATER LEVEL 0 <br />OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL <br /> <br />0 SOIL BORING <br /> <br />0 DESTRUCTION: <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br />......., <br />0 INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION IS— ve...s....s. DIA. OF CONDUCTOR CASING NiAk 0 <br />DOMESTIC/I' PE FUVATE 0 GRAVEL PACK/SIZE TYPE OF CASINO/ST EEU 7-,A,,,,, PVC Po L DIA. OF WELL CASINO 0 <br />PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL —I 3 SPECIFICATION R <br />El IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY V ,-...) GROUT BRAND NAME E 1, . <br />NI MONITORING GROUT SEAL PUMPED: MY.. ON. CONCRETE PEDESTAL BY DRILLER: 0 Yoe 0 No $ <br />APPROX. DEPTH q 5 LOCKING CHESTER SOX/STOVE PIPE S <br />PROPOSED CONSTRUCTION/WRUNG METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER <br />I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPUCAT1ON AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORE FOR WHICH, <br />THIS PERMIT 19 ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES'- <br />THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF 114E WORE FOR WHICH THIS PERMIT 18 ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br />CALIFORNIA.' THE APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL !ROOMED INSPECTIONS AT 120111 41111-3823. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br />TIPP .B.ALVAJr--ill 0,44.0-5etit----- Date I 24 /i Signed X (411/1,4___ 3114.4.1-• <br />PLOT PLAN (Mow to %Wel Sudo to <br />NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY.