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SAN JOAQUIN COUNTY PUBLIC EALTHB EIRVICEG ENVIRONMENTAL HEALTH DIVISION �1 v P,O, BOX 388,304 EAST WEBER AVENUE, STOCKTON, CA 9520138& FEB 0 3 1997 (209) 468-3420 NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED ENVIRONMENTAL HEALTH (Complete In LlpOettt) PERMIT/SERVICES APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER a-11116.3 AND THE STANDARDS OF SSM JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORE93/Oq APN/ L\ LR.OV 1rJ�O9C 16±L (-'5-�1L\APk -) CRY { G/•ci�L✓�L (� PA�RLC1EL SQFJAPNI OWNER'S NAME CA- r' MDRE38SW \T'.•pAl i LJ- %ff qS +L PHONE I CONTRACTOR N✓ ' nlL-1^ � ^ � �teA �ISCA1�"� 2- E10N PHONE ESUBCONTRACTOR G=1,5 �"uW TYPE OF WELVPIMP: ❑ NEW WELL ❑ ME CEMENT WELL MONITORING WELL' L�-� ❑ OTHER ❑ INSTAILATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑New❑Repeb H.P. DEPTH PUMP BE —". FIRST WATER LEVEL O (TYPE OF MMPI ❑ DVT-orGERVICE WELL ❑ GEOPHYSICAL Mao ❑ SOIL BORING 9 ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL I❑11�OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D 11DOMESTICRPIVATE Hp GRAVEL PACKISIZE TYPE OF CASINGISTEEVPVC Vc-- DIA.OF WELL CASING 4 O ❑ PUMCMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL ^ - 3-5 SPECIFICATION ?E R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED �B(V (y. Cn GROUT BRAND NAME p E 0 MONITORING y GROUT SEAL PIMPD: t2YVs Ne CONCRETEPMESTALBYDWLLER:❑Y. 54Ne 9 APPROX.DEPTH C'~ LOCKING CHESTER BOX/STOVE PPE 9 PROPOSED CONSTRUCTIONIDNLUNO METHOD: MUD ROTARY AIR ROTARY AUGER- CABLE OTHER I M9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH GAN MAGIAN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE GAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 091SRUM,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-6 COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR-9 HIRING OR OURCONTRACTINGSIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN't COMPENSATION LAWS OF CAUFORNIA.' TIE PPICAI MV A 110 ADVANCE FOR ALL REQUIRED INSPECTION*AT 120t1,441J 23. COMPETE DRAWING AT LOWER AREA PROVIDED. 81'm X i i TIS. POT PUN ID,.w 1.SP.I.I Bp.ls 'le 1. NAMES OF STREETS OR ROAO9 NEAREST TO OR BOUNDING THE POPRITY. 4. LOCATION OF IPOUSE SEWAGE MBPOSAL SYSTEM OR P orOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE GRIMM SYSTEMS. 3. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. DEPARTMENT USE ONLY 7 ApPB.Nbn A.pIM BY MI. -A,.-Ar. 6 OrmA I.P.ft.0, Dae PMnp In.p.11en By MI. D.Ruabn Imp.,bn By Cemmn,l.: � ,/✓Cis `Y P/1'L _ / L e A�".^' `�a„/L[ Q � 77-17-- ACCOUNTING ONLY: AID' FAC' PE CODES FEE INFO AMOUNT REMITTED CHECKNICA*N RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE ?�0/ 100300 -X4A- 2-317 2,9/ Pub.Health Serv.-Enviro.173(3/96)