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�.........,� ,vn ■■r.r_rlrtasetr rcnIli SAN JOAQUIN COUNTY PUBLIC HEALTH SE JES ENVIRONMENTAL HEALTH DIVISION P.O. 80 304 EAST WEBER AVENUE, STOCK, CA 95201388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triprwatel APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SA JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER j�9-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESS/OR APNt S CY I S W /ff f'15t Ova l CITY jbd- e-17n PARCEL 81ZE/APN# �•y OWNER'S NAME 2aD4 S ADDRESS//9o0_S'. ilnlb.+� ed A417kC"l, PHONE# gz`ins CONTRACTOR �5 �[ 1 1 (� (�j-� ADDRESS •V {�'� LIC#6 / r� PHONE SUB CONTRACTOR t t— ADDRESS h' j LIC# PHONE i > 7 TIVL TYPE OF WELL/PUMP: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR , VAPOR EXTRACTION WELL# New 13❑NeRepair H.P. DEPTH PUMP SET FT. ' FIRST WATER LEVEL (TYPE OF PUMP) ❑ OUT-0F-SERVICE WELL C1GEOPHYSICAL WELLS XSOIL BORING 1:1 DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q ( - ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION O t DIA.OF CONDUCTOR CASINO ,. C1D DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELJPVC T V(– DIA.OF WELL CASINO ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL_ SPECIFICATION , ❑ IRRIGATION/AO ❑OTHER GaoLrT SEAL INSTALLED BV n! F� GROUT BRAND NAME GR F Iq MONITORING GROUT SEAL PUMPED: ❑Yee [IN. CONCRETE PEDESTAL BY DRILLER:❑Yaa [IN. 5 APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIP�E� J( 5 PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER / 1 '014erl adC�Ss T I' 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,a O RULES At REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHI( THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFI' THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS CALIFORNIA.' THHEE APPLICANT MUST-CALL',� 24 HOURS IN ADVANCE FOR ALL REQUIRED 1Nr/��►E3 CTIONS AT(2001448123. COMPLETE DRAWING AT LOWER AREA PPRROV'IIDED. 4 Stoned X L/ C �'(�'�" Title / `ec-4 ��Ql0 it, Date / Go ! c PLOT PLAN(Draw to Soalo)Scale I 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ......:.......:.....'�.....i.. .. . :.......:............... .:................. ......c..... ....i.......;............ .... .. .. .. .. .. .......... ,.....E.. ..i ..;... ..... ............'. :........ . ...... .....:............••,.....:..............:.......:..........................:.......:.......;......:..... ......:;.... - .....................i......?.......:............ ......... .. .. ........ .. .................. .:.. ................'............. .. .. .. .. .. ..:.. i. E. :. .i.. ..i........ .......�•��.�.i.. ...... ............. t .............. ................ ..... . .. .. .. .. .. .. .. .. .. .. ...... IL ....................... .. .......................................I .................... ............ DEPARTMENT USE ONLY Application Accepted By f1A Date 1 17114,14Area Grout inspection BY 1( O t� 12 O gyp)--P Onto Pump Inspection By Date Destruction Inspection By Date Comments: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT RE0,41ITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE