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r61, NELiiftiMP PERMI'►..#� <br /> SAN JOAQUIN CDUNT`; PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 30.4 ;.HST WESER AVENUE, STOCKToN. CA 95201388 <br /> 12391 468-3420 <br /> NlJN•BFruA0AuLE lEHMlT ;1(piuE9 1 YEAR PR ' DATE ISSUED <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT IA DI/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 19 MADE IN COMPLIANCE WITH SA <br /> JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THF STANDARDS OF SAN JOAOUIN COUNTY pUBLIC HEALTH <br /> JOB ADORE83A7R API# SERVICER,ENVIRONMENTAL HEALTH DIVISION, <br /> / �� , V <br /> CITY ���[ Pr W PN <br /> OWNER'S NAME p a, �N p- <br /> , AOORFSS O C S Gt/ r D <br /> CONTRACTOR PHONE/TCC✓`.p✓�yf-'p /�- mar •,i z 4a �yss- <br /> ^ ADDRESS a.hr/� SK # 3 <br /> SUB CONTRACTOR CT/ SONE f -�70'3i <br /> r I ADORESY,17�j <br /> TYB (� w 2 . LIc# ps7 `1 <br /> ��.r PHONE/ <br /> PE OF WEUJMMF: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORPNOELL WI <br /> ❑ INSTALLATION ❑ OTHER <br /> ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR © VAPOR EXTRACTION WELL <br /> (TYPE OF PUMP) UMP SET_Fr.❑New❑Repair H.P. DEPTH PFT. <br /> FIRST WATER LEVEL _ <br /> 0OUT-0FSERVICE WELL ❑ GEOPHYSICAL WELL+ <br /> ❑DESTRUCTION: J ! <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION_. �, (~ ti OIA.OF CONDUCTOR CASINO A <br /> ❑ DOMESTICMMVATE ❑GRAVEL PACKISIZE TYPE OF CASING/STEEL/PVC D <br /> © PUSLIC'MUNICIPAL - DIA, F WELL CASING <br /> ❑DRIVEN DEPTH OF GROUT SEAL <br /> 11IRWOATION/AG ❑OTHER SPECIFICATION <br /> O <br /> FICATTON GROUT BRAND NAMR <br /> GROUT SEAL INSTALLED By t^-L E O tY <br /> 13MONRORINO GROUT SEAL PUMPED: [01YA E <br /> ^) � CONCRETE PEDESTAL BY DRILLER:❑Y« ❑Ne g <br /> APPROX.X.DEDTN ( J <br /> LOCKING CHESTER BOXMOVE ptPF <br /> PROPOSED CONA71RUCTIONIDMLL1NG METWOD� MUD ROTARYS <br /> AIR ROTARY AUGEp CABLE OTHER <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES,STATE LAWS,AND RULER AN[ <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOtLOW`tW:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICI <br /> THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEWEA71ON LAWS OF CALIFORNIA,- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIEL <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PFRFORMANrF OF THE WOR(FOR WHICH THIS P£P.MIT IS ISSUED,I SHALL KMPLOY PERSONS SUBJECT TO WORIURAN'i COM100/111AT10N LAWS OF <br /> CAUFORNI RRE AP ANT MUST CALL 24"OL-PS IN ADVANCc FOA Ai.�:e�.:�nLO.NaPE{TIOh{,aT L20111 N3i23, CO)iPLtET DRAWING AT LOWER AREA PADV[DED, <br /> Slptyd X Title % �`+�(��./1 <br /> Dote <br /> •to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOU PLOT PLAN ID,—to Sealey Seal. <br /> NDING THE PROPERTY, <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. �• LOCATION OF HOUSE BEWA(GE DISPOSAL SYSTEM OR PROPOSED <br /> 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS.AND WALKS, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY RT. <br /> ON THE PROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT USE ONLY �'j <br /> Application Acomted By {'ate'1�:/_'`r Date L Q Ar LOR y' <br /> Grote Inew lon By Date Pttme Insoocilon By Date <br /> Ostruction Inspection By Date <br /> Comments: <br /> ACCOUNTING ONLY, AID# FRCP <br /> PE CODES FEE INFO AMOUNT REMITTED CHE ICASH RECEIVED BY DATE PEPOWT/80 MCE REQUEST NUMBER INVOICE <br /> zil. 0916 <br />