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ii APPLICATION FOR WELUPUMP,,PERMIT ` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ate_ ENVIRONMENTAL HEALTH DIVISION.'.; ` °'"x'304 -EAST WEBER AVENUE,•STOCKTON, CA 95202 (209) 468tii420 IfDil•REFUNDABLE PERIRIT EXPIRES 1 YEAR FROiK DATE ISSUED mplets stel APPLICATION N HERE EL MAGE TO THE SAM CHAPTER JOAQUIN_1 COUNTY FOR PERMIT TO CONS RUCT�ANDIOR INSTALL THE WORT( OESCIgBEO. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9.11 S.3 AND THE STANDARDS OF SAN JOA OWN COUNTY Pt)6W HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESSA7R API! � � � �,. '� Q �-, p j y, ` . c 7 wee I'A PARCEL BIZFJAPJP OWNER'S NAME 1�1 �j [' Iii � o t , S 'fid N V'1 ADDRESS J�-7 �Y' Qt r�v� . ^. ^ O� CONTRACTOR—<Ami4D ` /PHONE! T �'��.IyI� r ii,� ' j f ADDRESS if J'a �iL3 r. LICIS O �Q ( PHONE I S 4i� f Sus CONTRACTOR Y - $CAVI v( f�{y ,y�'�+ql ADOhEes J %A (pi �s AQP -A— Llcr b�� t05 4PHONE TYPETYPE OF LUPUMR ❑ HE4V WELL © REPLACEMENT WELL ❑ MGMrrDRING WELL # ij ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR © CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # ❑Hew ❑ Rapid, H.P.:{ 1 (TYPE OF PUMPI DEPTH PUMP SET FT, jj FIRST WATER LEVEt O ❑ OUT -OF -SERVICE WELL ❑ OEOPHYSICAL WELL / ❑ DESTRUCTION.- it INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A �A AA ❑ INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION—Am ppY'r I� DIA. OF CONDUCTOR CASINO Y'► ❑ OOMESTICIPRIVATE 11 GRAVEL PACKMfZE TYPE OF CASINGISTEEUPVC W r DIA. OF WELL CASINO `_,/L A p NIC ❑ PUB=IMUIPAL 11 DRIVEN DEPTH OF GROUT SEAL �.t �iy SPECtr1CAT1oN __, NIA _ R ❑ IRRIGATION/AG XOTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME p ❑ MONITORING GROUT BEAL PUMPED: Yr I] Ne ij CONCRETE PEDESTAL 9Y DRILLER: ❑ Y. APPROX. DEPT" LOCKING CHESTER BOXMTOVF PIPE S PROPOSED CONOTRUCTRONIORRU lNO METHOD: MUD ROTARY--�� AIR ROTARY AUGER CABLE OTHER Lm I HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AMO REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S MONATURE CERTIFIES THE FOLLOW": WING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 914ALL NOT EMPLOY PERSONS SUBJECT TO WORIMAN'B COMPSRSAT10N LAWS Of CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CO"TRACTIMG SIGNATURE CERTIFIES THE FOLLOWING: ' 1 CERTIFY THAT INTIM PERFORMANCE OF THE WORIC FOR WHICH THIS PERMIT 19 ISSUED, 1 SHML EMPLOY PERSONS SUBJECT TO WORIOIMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT I T CALL 44 HOURS IN ADVANCE FOR ALL REQUIRED INOPECTIONO AT 1200140044". COMPLETE DRAWING AT LOWER AREA PROO�VIDED.� t p p swodX I Title f / 1,ii+iJl4'JI.,S.i.,_. Date_�71Z1'7�7/3 PLOT PLAN IDtm to eaetel Saida • to . i 1. NAMES OF STREETS OR ROADB NEAREST TO OR BOUNCING THE PFOPERtY. '4, LUcmioN OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY, OIVB'IO DIMENSIONS AND NORTH DIRECTION, 11 EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTI.M ..0 AND LOCATION OF ALL EXITING AND PROPOSED S. LOCATION OF WELLS WITHIN RAMS OF ONE HUNDRED FIFTY FT. STRUCTURES. .. AND.WALKS—' -_... _ _. ._._,: , nu•TNF!PGOPFRT.Y_na.-^_e::meter• •�,...�...,......_. s R AA o - y n NOtr1H ACACIA AVENUE z n p O Application Afefpted 1 6.etn k..peetlen Br^ Deftnetlen Impoetlon DEPARTMENT USE ONLY Date Pimp Impeettan BY_ o in v e Oft. T xi O A.» + _ Dote _ (:- ACCOUNTING ONLY: AID# T FAC! I -� PE COOED FEE INTO AMOUNT REMITTED CME fCAOH RECEIVED BY DATE i' FERMITISERVICE REQUEST NUMBER INVOICE Pub Health Serv. - Enviro. 173 (1/97) }