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S JOAOUiN COUNTY PUBLIC HEALTH SEqVICES' T � ' <br /> *� ENVIRONMENTAL HEALTH DIVISIC <br /> 304 EAST WEBER AVENUE, STOCKTON, ff95202 �; 4 ,J�$ <br /> (209) 468-3420 <br /> RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' ' r- '' ! <br /> Momplaw In TriplinL77 G F='1,�i ' ^Imo'.'•' r4 <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAGUNN COUNTY FOR A PERMIT TQ CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.T108 APPLICATION 18 MADE IN COMPLIANCE WR11$AN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENWRONMENTAL HEALTH DMMMoN. J <br /> JOS ADDRESSMA APNf 3 �S arr i PARCEL SIZElAPFtf `•�3� 04'o`�C��] <br /> OWNER'S NAME 4IZOfhP= ADDRESS <br /> --1PHONE► <br /> CONTRACTOR0". " iV _ ADDSS /V <br /> aonce <br /> PHNE I 4&/K� f� <br /> SUB CONTRACTOR ADDRESS LIC* PHONE R <br /> TYPE OF WEUjrUMF- 64m WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r <br /> ❑Naw 0 AW.11 H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> {TYPE OF PVMPI <br /> ❑ OUT-OFSERVICE WELL ❑ GESI <br /> OPHYCAL RING WELL f BOIL BO7 <br /> ❑DESTRUCTION: <br /> INTENDED USE 7YPE OF WELL CONSTRUC710M SPECIFICATIONS A <br /> D eLI l <br /> INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_ „ . DIA.OF CONDUCTOR CASINO D <br /> ❑ DOMESTICRW VATE ❑GRAVEL PACIVS17E TYPE OF CASINGISTEEUIPVC DIA.OF WELL CASINO O <br /> ❑ PUBLICRAUNICIPAL 0 VEN r_ — DEPTH OF GROUT SEAL y e�/r�1 SPECIFICATION R <br /> ❑ I GATIONIAG HER GROUP SEAL INSTALLED BY (1 �.Pc� GROUT BRAND NAME_ E <br /> MOMTORING GROUT SEAL PUMPED: ❑Yea ❑Ne CONCRETE PEDESTAL BY DRUITt❑Yr ❑Ne S <br /> APPROX.DEPTH G (�G�t��Jl� LOCKING CHESTER BOXMTOVE PIPE S <br /> PROPOSED CONSTRUCTION/0"LLTNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER fi <br /> I HEREBY CERTIFY THAT I HAVE PREPARED TMS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AHO <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'t CERTIFY THAT N THE PERFORMANCE OF THE WOW FOR WHICH <br /> THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATTON LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUS-CONTRACTINO SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMANS COMPENSATION LAWS OF <br /> CAUFORMA.' T CANT MUST A URS IN ADVANCE FOR ALL REMMI120 INSPEE�CTIOOONNS AT 12001441111-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Sipped X Th10_- 4JCiVWvJI+� .... .� Dati_GY • U <br /> PLOT PLAN M-n to Saalal Sella 'to <br /> I. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY, t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYSTETAD, <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 5. LOCATION OF WELLS WrTHN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DWVEWAY8.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, <br /> .;.....E... .. .. -...... .. ...... .. _ .. <br /> t1..Q.. f ... <br /> DV1 <br /> .....:.... <br /> .:.:.:..:.... <br /> ................................. <br /> ..:............:.......:......:.......: <br /> ......:...... <br /> DEPARTMENT USE ONLY <br /> AFPliaaelen Aoaepted BY {} <br /> Dato V6 Mr <br /> fn <br /> beto`�RP ImPeetlen Gr beta <br /> Dn+enetbn huesetMn Br - <br /> Dale <br /> Ce.nmenlr: <br /> ACCOUNTING ONLY: A,p► PACT <br /> PE CODES FEE tNFO AMGUIjT RMTTED CHECKFICASH <br /> RECEIVED BY BATE <br /> �O I'W"TMERVICE REQUEST NISIM9r INVOICE <br /> a <br /> Pub.Health Serv.-ERvlro.173(1/97) <br /> o .SUN 0 8 1998 <br />