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_ _SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES y ENVIRONMENTAL HEALTH DIVISf i4 EAST WEBER AVENUE,STOCKTON, 95202 (209) 468'•3420 109-REFUNDABLE PERMIT EXPIRES I.YEAR FROIN DATE ISSUED IComplolo In TTIpRastol APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE W COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH D1VIB10 i� 13 _ 754-0 J08 ADORESSIOR APNf 7 0 � Iy . E 1(ADorado S �. CITY S�/�0 c �r��1� f PARCEL WVAPHN 100Y 130 OWNER'S NAME [ker 1,s Me br 1 ` y, ADORERS 70 6 �I • �i DO 3,4 Q6 PHONE f � �'•-;46 N CONTRACTOR AJv�a +1.c._L (y+e FIV VII 1"0KNI'+M,f 4 ADDRES11408� �� Wi I P-1 *4yUCf D 903 PHONE f- 4 7� 006 SUB CONTRACTOR ADORESB LK:f PHONE'! TYPE OF WEEUPUMP, ❑ NEW WELL ❑ REPLACEMENT WELL ❑MONITORING WELL f ❑ OTHER ❑ RiBTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL! ❑New❑P.,& H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OIfT-OFSERVICE wELL ❑ GEOPHYSICAL WELLf- ® SOrt.somm g ❑OESTRUCTtON: _ I INTENDED USE TYPE OF WELL CONSTRUCTION 8PEtAFICATIONS A j fP ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASRM D ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISRE TYPE OF CABnNIGIVEELIPVC Tr DIA.OF WELL CASINO p 1 ❑ PUBUCPMUNICIPAL ❑DRIVEN ' . DEPTH OFGROITT SEAL _ T. i•- SPECIFICATION R jl 1❑� 13SE IRRIGATION/AO OTHER � � � GROUT AL MBTALLEO BY SPOUT BRAND NAME_ air /t( -+ .F tS 1 MONITORING j GROUT SEAL PUMPED: [jYw ®Ne CONCRETE PEDESTAL BY DRILLER:❑Y.'..[&I, s APPROX.OEPTN___, - _ ___ 6's - LOCKING CHESTER BOXlSTOVE PIPE PROPOSED CGN2TRVC710NR]RR.LINS METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 21'$"t 1 HEgEBY CERTIFY THAT 114AVE PREPARED THIS APPLICATION AND THAT THE WORK VVAJ BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. ROME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR NMICH THIS PERMIT 16 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WO*KMAN'S COMPENSATION LAWS OF CALIFORNIA.* CONTRACTOR'S HIRING OR RUB-CONTRAtTm SIGNATURE CERTIFIES _ THE FOLLOWING: 'T CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR.ALL REGUMM Ift*M"ONs AT 1"0144*-2422. COMPLETE DRAWING AT LOWER AREA PROVIDED. w Signed x c1 ,.. nne 5+fit 1te r S Ya F .6 to ` I T . D.t. 3-1.5•-a $ NAT FLAN ID.ew to Beelol Sado •ro - 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERY• - 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GING DIMENSIONS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. OIMENSIONED OUTLINES AND LOCATION OF ALL EXI8TING AND PROPOSED - S. LOCATION OF WELLS Wrn*N RADIUS OF ONE NUNOMD FIFTY FT. STRUCTURES.INCLUMNO COVERED AREAS SUCH AS PATIOS,ORIVEWAYB,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. - .�_.. d...Li.....i......'...... i DEPARTMENT USE ONLY Applleallen Aovmted BY G.eul S»veellen BY Dn Pump Impeedon By Oe1e O-o mtlen Impaction By Dete I ACCOUNTING ONLY; AJbf FACE ' PE CODES EE INF6 AMOUNT REMITTED CHECIUICASH 'RECEIVED BY DATE PERMITRIERMRE REQUEST NUMBER INVOICE !E01 00 d z D D 5-3 Pub.Health Serv.-Envim 173(1/97) OCT 2