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r°rDilCio90 ug 1't:;` jrdylVl nER{VIi& a f ( RAN .111AQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL. HEALTH 01VISION P 0 ROA 386, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.286 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSUED [Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TG CONSTRUCT ANDIOR INSTALL LHE YJGRK DESCRIBED.THIS APPLICATION iS MADE IN COMPLIANCE VJI-TH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY`PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNKqLj �' CrFY { '� C�1 PARCEL 512E/APNN OWNER'S NAME S' f� ✓ ADDRESS [,,�n//I !� PHONE#S3 CONTRACTOR �✓� / i--al fi'I.� �� 1C ADDRESS Y(J CYJr{ � �� LICK�- PHONE K 7 Al SUB CONTRACTOR/ ADDRESS LICK PHONEK _TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL K ❑ OTHER ❑ INSTALLATION P!'WELL SY TEM REPAIR E] CROSS-CONNECTREPAIR ❑ VAPOR EXTRACTION LLWELL K' J 11N—❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVELLY) , O TYPE OF PUMP[ � ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL K ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A —E] ]INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D (_] DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE FYPE OF CASING/STEFUPVC DIA.OF WELL CASING D ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E _ ❑ MONITORING GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER:❑Y- ❑No S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE S PROPOSED CONSTRUCTIONIDRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER ^1 I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL 13F DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH C THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES f THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OFA CALIFORNIAIHE APPLICANT H CALL 24 OURS IN ADVANCE FOR ALL REQUIRED INSP TIONS AT(209)4883423. COMPLETE DRAWING AT LOWER AREA VIDES. Sier»d X Title Det. �� —T PLOT PLAN(Draw to Sutel Sulo "to ^� 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION Of ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,ANO WAI KS. ON THF PROPERTY OR ADJOINING PROPERTY. I: i . . �1 J .. .....: ....:.. .. .. .:.. { .. \ .. .. .. ... . . f .. . . V