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ti SAP" '7AQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION Ge 304 EAST WEBER AVENUE, STOCKTON, CA vb202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 7� (Compl*t* In Trolks(s) APPLICATION 18 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 WRIT SANz r/ JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 L1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNW PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION.. ?j JOB ADDRESSOR APNI �� s / Vlr-�h. r ` t ,- 0 /moi CITY p 5*0 C._1�.� ✓i PARCEL SIIZEJAPNF 16 / 17-0 1) J 1�' OWNER'S NAME 4 ✓4 t K S r" p ADORE PQ p I D 30 5 -ti 4,owIS , /* ! JII f PHONE I ,314-' Z5/ -74, 74,7J s14U iIsba lI.,sre, UCF PHONE I_6 19'1191-71 3 Pe II GLzIG SUB CONTRACTOR_ Gr t_"Q)11 '!20 ADDRESS 6S0 PoOV__R gd UC1415 1Ls PHONEF"]d ZS'3 13 -59'o TYPE OF WELLIPUMPI f SJ NEW WELL ❑ REPLACEMENT WELL ta MONITORING WELLI I_1 OTHER �Qi ✓tuq ❑ INSTALLATION ❑ WELL SYSTEM REPAIR EICROSS -CONNECT REPAIfr p 2 V `� ❑ VAPOR EXTRACTION WELL F ✓\/ 1:1 Ne- 111Repair H.P. DEPTH PUMP SET FT. n•7 FIRST WATER LEVEL 0 (TVP{ OF PUMP) 11vp� OUT -OF -SERVICE WELL �•�`�/ EI GEOPHYSICAL GEOPHYSICAL WELL `-Y BOIL SONNG S ❑ DESTRUCTION: INTENDED USF TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION _ - DIA. OF CONDUCTOR CASINO ❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASINOISTEEUPVC DIA. OF WELL CASINO ❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION_ ❑ IRRIGATION/AG ❑ OTHER GROUT BEAL INSTALLED BY GROUT BRAND NAME_ 0 MONITORING Q r GROUT BEAL PUMPED: ❑ Yee [IN. CONCRETE PEDESTAL BY DRILLER: ❑ Yw ❑ Ne APPROX. DEPTH S O T �G� LOCKING CHESTER BOX/STOVE PIPE _ n PROPOSED CONFTRUCTIONrMLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER '..OKC. I W 4LvCW-Ctt V' R"I I HEREBY CERTIFY THAT 11(AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STAT WS, AND RULES AND -41 REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'$ SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERTORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: ' I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'* COMPENSATION LAWS OF CALIFORNIA.' APPLICANT VST CALL 24 HO Ri IN ADV NCE FOR ALL REQUIRED INSSP/JWTION* AT 12061 4654422. COMPLETE DRAWING AT LOWER AREA PROVIpED. $Ipned X _7 Title L/y H'4 -e / PLOT PLAN (Drew to Boole) Boole 1. NAMES OF STREET$ OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. MW -13 FORMER DISPENSER EARTHGRAINS PLANT BUILDING mw -y Mw -12/ \ 0 I 0 y 0 p RCPT -1 / MW -8 \ -S��==-=J 'tW_5-A PIF- MW -i 1 AMEN IO.OW _LON UIESEL-FUEL UST :MOVED 09/89) II Li to 4, LOCATION Of HOUSE SEWAGE pSl'OSAL SYSTEM OR PFOP08ED EXPANSION OF SEWAGE DISPOSAL SYSTEM*. 11 S. LOCATION OF WELLS WITHIN PADM$ OF ONE HVNDRED FIFTY FT. ON THE PROPERTY OR ADJOINING PROPERTY. 0mw- 1 GROUNDWATER MONITORING WELLS FORMER 20.000 GALLON DIESEL -FUEL UST (REMOVED 09/89) r a 3 cr cr 0 0 a a S 0 0 * CPT- 1 PROPOSED CONE PENETROMETER SAMPLE LOCATION * CPT -3 POTENTIAL CONE PENETROMETER SAMPLE LOCATION /` �y / DEPAATMENT USE ONLY !/ y Appllcetlon Accepted BY 2 �� /(� 4.+G-� " � � _ Dale ! G/ C� Moe ; vete fl mP Inspection By _ _ _ Date Dost,twilen Inspection By .�" ./ .i L/` C-�l Dot. S Commenlat 5_-c?,C' l � t>. t�Cyk ijl � zz_ 5 '/ /j ACCOUNTING ONLY: AID# FAC/ PE CODES FEE INFO AMOUNT REMITTED RIECK# AFH RECEIVED NY 11 DATE PERMITISERVICE REQUEST NUMSER INVOICF 835' 1 o Pub, Health Serv, • Envlro. 173 (1/97)