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SAN JOAQUINI ICOUNTY PUBLIC HEALTHRSbr CES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 9520/388 (209) 468-3420 C Lf {7h Ce0 1 ` NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APPLICATION IS HERE EL MADE TO THE SAN JOADUI 1 COUNTY FOR q PERMIT TO CONSTRUCT ANpIOR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN ICompMd in Tlgligtel JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 91115.3 AND THE STgNOARDC OF SAN T ANDIN COUNTY PUBLIC HEALTH SERVICES, IS APPLICATION ION HEALTH DIVISION. JOB ADDRESSOR AM, �L` /• S Y ALU y C1C�' CITY TT?J OWNER'S NAME e, m4 t V�LLey T��-^ nni�ll KK�' L=�PARCEL 81ZE/gPNI CONTRACTORh�ADORESS — -/ALL/Yl IKLt'/N/-e PSL O 111-1--2-31V 1 SUB CONTRACTOR ADDRESS�Ti Z F -FMONE A /L L-J'j 1 l� --�>-_->`rzrx sr LIG. s7z ZE'f J- ,,s ADDRESS PHONE I TYPE OFTYPE pF—MP, ❑ NEW WELL LIC( PHONE ❑ REPLACEMENT WELL ❑ MONITORING WELT ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ OTHER_ ❑Nom,❑ ❑ CROSSCONNECT SETECT REPAIR ❑ VAPOR EXTRACT( RYPE OF MMPI Repalr H P. DEPTH NMP SET—FT ✓ ❑ OUT-OF-SERVICE WELL FIRST WATER LEVEL LST ❑ GEOPHYSICAL WELLS O W DEBTRUCTION (,4'/tti_ � _ /LL YI n IL'L SOIL BORING INTENDED U6E TYPE Of WETL ❑ INDUSTRIALDO;li 1 li NDN SPWE 0EGIFICATION6 --�— OPEN BOTTOM DIA,OF WELL EXCAVATION ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZEDIqOF CONDUCTOR CASING A / 11 . -- ❑ NBLIC/MUNICIPAL ❑DRIVEN TYPE OF CASING/STEEVPVC D=_ El DIA,OF WELL CASING IRRIGATION/AG ❑OTHER DEPTH OF GROUT SEAL --� D GROUT SEAL INSTALLED BY SPECIFICATION - ❑ MONITORING R GROUT SEAL NMPED: ERGOT BRAND NAME 1_� APPROX.DEPTH �S I tv Oct / ❑Y^ W No CONCRETE PEDESTAL By CONSTRUCTION DRILLER:LJ y.. LI�J�rye PROs POSED LOCKING CHESTER 00%/STOVE DICE O /DPoWNG METHOD: MUD ROTARY AIR ROTARY AUGER s I HEREBY CERTIFY THAT I HAVE PREPA CABLE OTHER � RED TNI6 A REGULATIONS OF THE SAN JOAOUIN COUNTY. NOMF OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH`(I (CATION AND THAT THF WOpK WILL BE DONE IN ACCORDANCE WITH SAN JOgOU1N COUNTY OPpINANCEB,STgTF UWS,AND gUlFS AND` /J THIS PERMR IS IS611E0.I6HAll NOT EMPLOY \IJ THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE SU JECT TO THE WORK"A WHICH THLISATION LAWS OF CALIFORNIA.- CONT CALIFORNIA.- ES E APPUCA MUST CALL M HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT PERMIT 11 SUED,1 SHA RECTOR'S HIRING OR SUB CONTRACTING SIGNATURE LAWSCERTIIIF LL EMPLOY PERSONS SUBJECT TO ER ARE APR COMPENSATION HADON UWS OF( 61proJ% � � _ � 120YI IBHJ�3D. COMPLETE pggWING AT LOWER AREA PROVIDED. r Tlll. E•�� MOT L NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROp_to Pgiylel So,. D.I. ), OUTLINE OF THE PROPERTY GIVING DIMENSIONS AND NORTH DIRECTION. to 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROMISED i. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 6 STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALK G. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. OF WELLS S. LOCATION RADIUS OF ONE HUNDRED FIFTY FT I ON THE PROPEHTy pq gOJO1NINO PROPERTY 1 � t RYz f �-Y eye 2-0 — tN PluPcseo �t7�L�� "AYC�I i sTruAcTgae tPrllltiab h` F"d 1l r - J I ( Btt51 rJ ®^ PR[,P gOYI> JAS I AoDEPARTMENT USE ONLY..TT --� vlicetlon AccepleE By i�L- 8, Ar. O V Pomp ln.Pectlan By De.tmctlon Imran len BY /I �%ro N tI b-cy D.te G c commenH: /.pN,"T/ w,I fC/• � ��Dale ACCOUNT T'No oN`Y. Ana FAC# PE CODES FEE INFO AMOUNT REMITTED EC /CASH RECEIVED BY DATE pEF1MIT/SEANCE REQUEST NUMBER INVOICE