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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, and Rules and Regulations of the San Joaquin County. Name owner or licensed agents signature certifies the following: "1 r certify that in the performance of the work for which this permit is issued, 1 shall not employ persons subject to WORKNAMIS COMPENSATION N Laws of California." Contractor's hiring or sub -contracting signature certifies the following: " 1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to IpRA AMIS COMPENSATION Laws of California." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL NEDUIREO INSPECTIONS AT (2011 481-2423. Complete drawing at lower area provided. Signdi•R^^<. / ' I /Ji (T A',A AgQ'^ Title&2.0 <_ DatC� A'a' /I PLOT PLAN (Draw to Scale) Scale • to 1. Names of streets or roads nearest to or boarding the property. 4. Location of home sewage disposal system or 2. Outtire of the property, giving dimens;ons and North direction. proposed expansion of sewage disposal systems. was 3. Dimensioned outlines and location of all existing and proposed 5. Location of wnus of 150 ft. on structures, including covered areas such as patios, driveways, the property QQF"aN1diA�xs xollper ty. and walks. . C._. kF}Je- t eas mas ^iOEPARTMEMT USE ONLY %W Application Accepted By /(/, Date P Grout Inspection By i i� �G%r--r-��'.i� Date % I"�� Pump Inspection BY Dace,`. Destruction Inspection By Date Cements: was ame P 0 BOX 388, 4",N., SAN JOAOUIN ST, STOCKTON, CA 99201388 V r_ 12091 4883420 MON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IGmpins in TrpFxub) Application is here by male to the San Joaquin County for a permit to construct arxl/or install the work described. This application is made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health mem Services, Environmental Health Division. l Jab Address/or APNN Z� i"� / /ppm/ "r City .1 - Parcel Site/APNN I 11_ Owner's Name / , 1 � : Lt�/ f v,G. t4p-u..raLddress c,1:/C,) 5- %. ; �� »�I v �� .1 ( W Phonesam II Contractor s /v I �G4 L't, 1I, rt .: Address Y -%l. rain eN- , / Lic#Phone B ��✓.-"3' x. 7 _ Sub Contractor Address Lich Phone R was TYPE OF WELL/PUMP: )Z�INEW WELL p REPLACEMENT WE LL ❑ MONITORING WELL N IT OTHER ❑ DESTRUCTION [) OUT -OF -SERVICE WELL O GEOPHYSICAL WELL Y 13 SOIL BORING O INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL N_ rr fN ;`NeR ❑ Repair X.P. < DEPTH PUMP SET 119{t FT. FIRST OUTER LEVEL ass (TYPE OF PUMP) INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (3 INDUSTRIAL OPEN BOTTOM DIA. OF WELL EXCAVATION Ic,>k DIA. OF CONDUCTOR CASING p .❑ [IDOMESTIC/PRIVATE T GRAVEL PACK/SIZE—AL TYPE OF CASING/STEEL/PVC r- t� DIA. OF WELL CASING SI [IPUBLIC/MUNICIPAL IT DRIVEN DEPTH OF GROUT SEAL O J SPECIFICATION '1 ';/-;" ti ❑ IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY /J b, - 'ROUT BRAND NAME .T a Y+ ❑ MONITORING GROUT SEAL PUMPED: X Yes [I No CONCRETE PEDESTAL BY DRILLER: p Yes IT No APPROX. OEPTR (i CHESTER SOX/STOVE PIPE ``L,OOCKING PROPOSED CONSTRUCTIONIDMLLINS MEINOD: MIA ROTARYa AIR ROTARY_ AUGER_ CABLE_ OTHER_ 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, and Rules and Regulations of the San Joaquin County. Name owner or licensed agents signature certifies the following: "1 r certify that in the performance of the work for which this permit is issued, 1 shall not employ persons subject to WORKNAMIS COMPENSATION N Laws of California." Contractor's hiring or sub -contracting signature certifies the following: " 1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to IpRA AMIS COMPENSATION Laws of California." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL NEDUIREO INSPECTIONS AT (2011 481-2423. Complete drawing at lower area provided. Signdi•R^^<. / ' I /Ji (T A',A AgQ'^ Title&2.0 <_ DatC� A'a' /I PLOT PLAN (Draw to Scale) Scale • to 1. Names of streets or roads nearest to or boarding the property. 4. Location of home sewage disposal system or 2. Outtire of the property, giving dimens;ons and North direction. proposed expansion of sewage disposal systems. was 3. Dimensioned outlines and location of all existing and proposed 5. Location of wnus of 150 ft. on structures, including covered areas such as patios, driveways, the property QQF"aN1diA�xs xollper ty. and walks. . C._. kF}Je- t eas mas ^iOEPARTMEMT USE ONLY %W Application Accepted By /(/, Date P Grout Inspection By i i� �G%r--r-��'.i� Date % I"�� Pump Inspection BY Dace,`. Destruction Inspection By Date Cements: was ame