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u(i <br /> �1 /J APPLICATION FOR LIPERMIT <br /> �ill//VVV/11 SAN JOAQUIN COUNTY PUBUBLICC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION li'(112 3 <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> 26 B ,I+d/NO REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED S <br /> ts <br /> APPLICATION 19 HERE BY MADE TO THE JOAQUIN C UNtV FOR A PERMIT TO CONSTTRC"plUCTIn Tilplicatel <br /> ANTIM"INSTALL THE WON(DESCRIBED.THIS APPLICATION IS M4ADE I CO PUANCE WHII SAN <br /> JOAQUIN COUNTY DEVELOPMENT THELE,CHAPTER 9-111 5.3 JAND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRE99IOR A�/�� I 1 CITY �✓{,-1414,- -1 �� PARCEL SIZE/APNI <br /> OWNER'S NAME //J� itw`. W'!'C-r� I.iIU�C.YXI11.4�AbOREee.y�nn3f)VI L�SnNt Z.:� fJ� .�FAS:.[I.�.l . P/HONE# '( <br /> CONTRACTOR ADORESS/'(,T 1. /) t..kT. 6_ UCF / E ESNE <br /> SUBCONTRACTOR ` ADDRERS UCF PHONE <br /> TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITONNG WELL I ❑ OTHER <br /> ® INSTALLATION ❑ WELL SYSTEM REPAIR Cl CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL 0 <br /> ❑N.❑Eb 0' ILP. CaDEPTH PUMP SFTje.Q_FT. FIRST WATER LEVEL O <br /> HYPE OF PUMP <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING B <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ® INOVETRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O <br /> ® DOMESM/PFUVATE 11 GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASINO O <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROW BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yr [IN. CONCRETE PEDESTAL BY DRILLER:❑Y- (IN. S <br /> APPROX.[NEVER LOCKING CHESTER BOX/STOVE RPE 5 <br /> PROMISED CONSTRUCTION)DRU NO METHOD: MUD ROTARY AIR ROTARY AUE EP CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAW PREPARED THIS APRJCATION AND THAT THE WOR(WILL BE DONE M ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT-S SIGNATURE CERTIFIES THE FOLLOWING:*1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALROPMA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: -1 CERTIFY THAT M TIIE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS BVWECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- THE 1�1PP{L�a}W MUUET.,C�AU 4 HOURI5 IN ADVANCE FOR ALL REOLARID INIUMMNE AT IZOSI ASSJ530. COMPETE DMVANO AT LOWER AREA/PRDVIDED. f(� <br /> el'r X /P"� L\lf /T f�'GR�e,+—/— Tltle 0.1�1�"��—�`� <br /> ROT PLAN 0.I.S.N.1 Be•N 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. C LOCATION OF 14OUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> Z. OUTLINE OF THE P OPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAOE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING ANO PROPOSED S. LOCATION OF WELLS MELTON NAME OF ONE HUNDRED FIFTY Ff. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR AOJOINRG PROPERTY. <br /> } <br /> P W <br /> *. <br /> N <br /> c Sr <br /> s <br /> p <br /> NOV 2 3 1998 <br /> SAN JOAQUIN(,UUN'I) <br /> PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> PAATMFNT USE ONLY ♦�\j) <br /> APPII.etlV AwwIW By I v L V`�`�- D.I. �V Ar•• <br /> 01.0 IAve.11en By D•te Pvnv I..n.ml..By D.I. �� 1 <br /> DnElnvllen Iwnedbn By Dela <br /> Commo-n•: <br /> ACCOUNTING ONLY: AID! FACE <br /> PE CODES FEE INFO AMOUNT REMITTED CHECKF ASH RECEIVED NY DATE PERMITISERVICE REQUEST NUMBER INVOICE <br />