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SAN JUAUUIN UUUMIT YU#LI6 MtALIM RtM1116t5 <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201388 <br /> (209) 4883420 <br /> HON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM D0.TE ISSUED <br /> IComPtate M TtiPlleard <br /> Application is here by made to the San Joaquin County for a permit to construct and/or install 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, Envirormental XealthDivjsion. <br /> _ Job Address/or APN% -37 <br /> city -,5;40C&10 A.1 Parcel Size/APN% <br /> Owner's NameTTOgn I—A-Q�j�/ FQY n'Lr Address Phone # <br /> Contractor DP��tI. r� wt�< Address— IQ 2A i # 162373 Phone # <br /> Sub Contractor Address Lic# Phone # <br /> TYPE OF WELL/PUMP: [1 NEW WELL 0 REPLACEMENT WELL [1 MONITORING WELL % [1 OTHER <br /> [1 DESTRUCTION 0 OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # 0 SOIL BORING <br /> INSTALLATION C1 WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # <br /> 5 u 6 A�New U Repair N.P. DEPTH PUMP SET Z i n FT. FIRST WATER LEVEL Ty <br /> (TYPE OF PUMP) �lepk-LCe, SCf0D-5z A. e <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> Cl INDUSTRIAL L1 OPEN BOTTOM DIA. OF WELL E%LAVATION DIA. OF CONDUCTOR CASING is <br /> r <br /> 0 DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE_ TYPE OF CASING/STEEL/PVC DIA. OF W k J{1�1.GM ' <br /> 0 PUBLIC/MUNICIPAL [1 DRIVEN DEPTH Of GROUT SEAL SPECIFI(�i Pf^N6L_ ;ham <br /> 0 IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY GROUT UNR[(Mfpi�•/I�AlI�`y ++ <br /> (I MONITORING GROUT SEAL PUMPED: 0 Yes ❑ No CO" 1E PEDE A�B�(pNJ LER: 0 Yes ❑ No <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE CA,, <br /> '''PhUJeI J�A`^'uIh/fr J•Tf q <br /> PROPOSED COMSTRUCTIDNiDRIILING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER_ CABLE_ OTHER 7.^�'R ��f y r <br /> _ I hereby certify that 1 have prepared this application and that the work will be done In accordance wt[h San Josgm n County Ordl nances, i <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or Licensed agent's signature certifies the fallowing: "1 <br /> cernty that int nce at the work for which this permit is issued, [ shall not employ persons subject to WORKMAN'S COMPENSATION _ <br /> Laws of Cal Ef ni a." Contr tor's hiring or sub-contrnp signature certifies the fol loci ng: " I Certify that in the )xrfarmence <br /> of the work or which this pe mit is iss sha1L o persons subj act to WORKMAN'S COIPENSAT ION Laws of California." THE APPLICANT L <br /> MUST CALL XOURS I AOYA ON ALL E I E T 12021{383423. Comp Leto drawing et�/ow�er arae prov/iJded'. - <br /> Signed X Titleate �3•� <br /> PLOT PLAN (Draw fo Scale) Scale. Nl9AC�_ <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 /> Application Accepted By Dete <br /> Date Pulp Inspection BY Date <br /> Grout Inspection By <br /> Destruction Inspection By Date Cmaeents: <br />