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APPLICATION FOR WELUPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 {209}4G8-3420 i NON-REFUNDABLE PERA!!T EXPIRES 1 YEAR FRLX- DATE ISSUED APPLICATION IS HERE BY MAIN 70 THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONS TRUCtVV UIlate 1AND1bReNSTALL THE OR+C DESCRIBED.7lR8 APPLICATION IS MADE IN CDFRPLIANC JOAON COUNTY DEVELOPMENT TITLE.CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUE WITH CANBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, 4 JOBADORES810q APNr Q�{ �. �c kvlmL j� +' ,�Ll CITY Y\I V�' D } ,,` _ 1A PARCEL SIZEIAPNr 1 OWNER'S NAME NA A,<1^�e.�t-W ��VW�1 �114.f�,'Y.I.T 4 �d ADDRESS o`� N A - �'y . ATU /l ,, PHONE r CONTRACTOR S Li S' ADDRESS I !� i4C O L, a [( .41 SU � -2q. C,PHONE. S TZ�2ZZ1iI I B CONTRACTOR 3 iL}1�1 {, 1 ADDRESSv TYPE OF WE MP- 'XNEW WELL ❑ REPLACEMENT WELL )irMOMTORING WELL r 3 ❑ OTHER ❑ rNSTALLATbN ❑WELL SYSTEM REPAIR 13 -CECT REPAIR CROSSONN3r k ❑ VAPOq EXTRACTION WELL I J ❑New 11 Repek H.P. DEPTH PUMP SET FT. fIYPE OF PVMP1 FIRST WATER LEVEL0 ❑ OIITOF-SERVICE WUELL ❑ OEOPHYSICAL WELL r �� ❑ BOIL BORING R ❑DESTRUCTION: �! INTENDED U&E TYPE OF WELL ! CONSTRUCTION 8PECIFICATIONat }' ' 13 INNDUS mAL ❑OPEN BOTTOM k �E ,/� A DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING NPT p ❑ DOMESTK:lPNVATE ❑GRAVEL PACKIBtZE TYPE OF CASINGMTEELA'VC DIA,OF WELL CASINO rr b 11PUSUClMUNIClF'AL ❑DRIVEN DEPTH OF GROUT SEAL �+h SPECIFICATION S C.vt. II CJ fRRIGATbNlAO MOTHER GROUT SEAL INSTALLED BY +VtW%'V, 3 pt GROUT BRAND NAME tC�rV��Ar MQNIfORING �y.,, T�� i� { f GROUT SEAL PUMPED: I Yee [IN. !1 CONCRETE PEDESTAL BY DRILLER:Cl Yes >esae S APPROX.DEPTH LOCKING CHESTER SOX/STOVE PIPE S PROPOSED CONSTRUCTIONlDNL.LJNG METHOD: MUD ROTARY AIR ROTARY AUGER /}! CABLE OTHER �I 1 HERBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN.JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGEWPO SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN 114E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 18"0,1 WfALL NOT EMPLOY PERSONS OULPECT TO WORKMAN'&COMPENSATION LAWS OF CALIFORNIA-- CONTRACTOR'S HIRING OR SUB-CONTRACTIb SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 8HA1J.EMPLOY PERSONS SUBJECT TO WOIIbNAN'S COMPENSATION LAWS Of CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOURED INSPECTION&AT 12"ll 44SU22. COMPLETE DRAWING AT LOWER AREA PROVIDED, qo Ghpmd X Title 'B't Gt.4"c'i'1 PLOT PLAN lbrsw to Saatsl Basle 'to I- NAMES OF STREETS OR ROADS NEAREST TO on BOUNDING THE PROPERTY, li 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUT(WIF OF THE PROPERTY,GrWM DIMENSIONS AND NORTH DIRECTION. I} EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTtW..S AND LOCATION OF ALL EXISTING AND PROPOSED 115. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, 'k STRUCTURES,INCLUDING COVERED AREAS BLICH AS PATIOS,DRIVEWAYS,AND WALKS. Il ON THE PROPERTY OR ADJOINING PROPERTY, 1 � F a: EL i a _ Lu o p 0 w woo/ o Z J •w P - �Sw w___ o a - p m U 4 6 py IANIIV l01DI HMUN w 4 •-- - :.. ...... .... li SJR - O O . adz oo �m 4 00 DEPARTMENT USE ONLY .} Apptlestbn Aeeepted 8jAK _ V\ ,_ II Date O+eut Impeatlon BE bale Pump Irapeetl"By I Date r Oeetniatten Impaction By beta li ' tv CommeMe: opt a ACCOUNTING ONLY: AID/ FACT I� s PE CODES FEE INFO AMOUNT REMITTED CHECr ASH RECEIVED BY DATE k PERMITISERVICE REQUEST NUMBHI INVOICE 2r Dt q of 9/$O M 1l tl - 1 k i} I Pub Health Serv.-EnvirG.173(1197) l _ a