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A SRNJUAIFUINCOUNTYPUBLICHEALTHSERVICES <br /> ENVIRONMENTAL HEALTH MVISION v <br /> BOX ass,445 N.SAN JOAQUIN ST.,STOCKTON,CA 952f 9 <br /> (209)468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES(YEAR FROM DATE ISSUED <br /> - {Complmts ht Tr{plleate) <br /> Application is here by made to the San Joaquin County for a permit to construct and/or instalt the work described. This application is <br /> made In compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> Job Address/or APN#43.3 N-MA-P«,74/ 7- city ! %Pw / <br /> Parcel Size/APN# <br /> Owner's Name / / /Address v• .5� '7 Phone # <br /> Contractor �iizbchi�l�l_�f9 !�/OYJ/Jclln.f 45 Address 601-(40-4dy Lic#r�7 �_p/ Phone <br /> Sub Contractor_ E� Address ' 1 �5 A16 1>4 °Cti4L{cp!,7a�tv7({7 - Phorw #?u7 <br /> TYPE OF YELL/PUMP: NEW WELL U REPLACEMENT WELL MONITORING YELL #�T�•••p-OTHER1W A - <br /> DESTRUCTION [l OUT-OF-SERVICE-WELL p GEOPHYSICAL WELL # 11 SOIL BORING <br /> (l INSTALLATION 0 WELL SYSTEM REPAIR [l CROSSCONNECT REPAIR 11 VAPOR EXTRACTION WILL # <br /> 11 New (1 Repair H.P. DEPTH PUMP SET FT.' FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> 11 INDUSTRIAL (I OPEN BOTTOM DIA. OF WELL EXCAVATION/ DIA. OF CONDUCTOR CASING��� <br /> U DOMESTIC/PRIVATE P-1ifAVEL PACK/SIZE TYPE OF CASING/STEEL/PVL DIA. OF WELL CASING "I!, _ <br /> H PUBLIC/MUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL ^� SPECIFICATION <br /> fl IRRIGATION/AG (1 OTHER GROUT SEAL INSTALLED BY. i 'dP�4WdUT BRAND NAME / <br /> [,.MONITORING f GROUT SEAL PUMPED: U Yes No p CONCRETE PEDESTAL BY DRILLER: ({ Yes 0 No <br /> APPROX.DEPTH �- LOCKING CHESTER Box/STOVE PIPE__ t1Y� fY[:Pa�K �FGv5� <br /> PRDPOSED COMSTRUCTIONIORILLINO METHOD: KUD ROTARY_AIR ROTARY /AUGER—zCABLE_OTHER_ <br /> 1 hereby certify that 1 have prepared this application and that the work wilt be done in accordance with San Joaquin County Ordinances, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Hone owner or licensed agent's signature certifies the following: "1 <br /> certify that in the performance of the work for which this permit is issued, 1 shalt not employ persons subject to WORKMAN'S COMPENSATION <br /> laws of California.- Contractor's hiring or sub-contracting signature certifies the following: " l certify that in the performance <br /> of the work for which this permit is issued, I shall employ persons subject to WORKMAN'S CCHPENSATION laws of California." THEAPPLICANT <br /> MUST CALL 2 ADV CE F Ll NS AT 12021488-3423. Complete drawing�a,��Jlower area�prov`ided. <br /> Signed% _ Title�1re .r Gramm'1K Date <br /> LAN (Draw to Scale) $Cate " to <br /> 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or <br /> 2. Outline of the property, giving dimensions and North direction, proposed expansion of sewage disposal systems. <br /> 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on <br /> structures, including covered areas such as patios, driveways, the property or adjoining property. <br /> and walks. <br /> DEPARTMENT USE ONLY ' <br /> .rr <br /> Application Accepted Date �2!6 Area <br /> Grout Inspectfon By - Dater Pimp Inspection By Date <br /> Destruction Inspection By Date Comments: <br /> ACCOUNTING ONLY: AID# FAL# - <br /> PE CODES FEE INFO AMOUNT REMITTED CHEC CASH RECEIVED BY PATE PEAMITJSERVICE REQUEST NUMBER INVOICE <br /> W 93 <br />