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• APPLICATION FOR IfELLIPUMP PERMIT 9SAN JOAOUIN CBUNTY BLIC HEALTH SERVIC S ffiA ENVIRONMENTAL HEALTH DIVISION P.O. BOX 38Et, 904 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468.3420 JUNO RIG I N A L NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED :..cIN L.wrJ?Y ICDmpMh in Triplicate) pljgtl^.�r A�_fi I SEl:'ACG3. APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TRIBWR/Q"I iDNiS MEDETM d6MICANCE WITH SA JOAQUIN COUNTY DEVELOPMENT TRUE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. Q' JOB ADDRESSMA AFFP''''N1 31ai w, FiPAr)gVAIr1-/TOjT ly''1V'P_ CITY_JrocAnT��✓t�1Y� yI Z�AA (, PARCEL SIZE/APN//00-17- 002r OWNER'S NAME T05e R 15501 eT a/ ADDRESS-319 1W• p�4igl4lA-1&r, A PHONE I /-O l7 CONTRACTOR G-/r'r-�q�� 'T br Ui nA ADDRESS L56 610kf- 'Ad UCI 185/65 PHONE#5/D-3/33-5'SUGs: SUB CONTRACTOR L,(.(.NZb / �( ADDRESS FQ QLD XJ;L r J WRQ UCI PHONE I IO -r TS p,7 TYPE OF WELUPUMP: % NEW WELL ❑ REPLACEMENT WELL L91 MONITORING WELL I l ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I v ❑New❑Rep.lr N.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL RYPE OF PUMP) ❑,OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSp r/ A 11 INDUSTRIAL 13 OPEN BOTTOM DIA.OF WELL EXCAVATION p DIA.OF CONDUCTOR CASINO O 11DOMESTIC/PRIVATE ®GRAVEL PACK/SIZE 54144 TYPE OF CASING/STEEL C V DIA.OF WELL CASING __ ry C 11 PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL n SPECIFICATION S L+lr[II-- 0 R II❑qq IRRIGATION/AG ❑ EDOTHER GROUT SEAL INSTALLED BY DNI I GROUT BRAND NAME rq E Hn MONITORING ^^ GROW SEAL PUMP : ❑Yr [IN. CONCRETE PEDESTAL By MILLER: Y. ❑No S APPROX.DEPTH (�O LOCKING CHESTER SOXISTOVE PIPE S PROPOSED CONSTRUCTION/DRWNG METHOD: MUD ROTARY AIR ROTARY AUGER h CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANI REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICI THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIE' THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(.FOR.WHICH THIS PERMIT 16 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMMSATION LAWS O CALIFORNIA.- THE'APPPLLICAN//T,,MUUS/ST CALL 24 HOOURR&IN ADVANCE IMRR ALL REOURED IINNS(P/EEC�TRIN/SO-A'T,1T20015I)�14SSJ422. COMPLETE DRAWING AT LOWER AREA PROVIDED. SIDmdX ( V/G9q UYII'/1,1Q TItI. ''l(,F I /VWYLK(1Ty D.I. -(-/'W 11 PLOT PLAN (Dr.t.S..I.N S..Is •to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL METING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. DFDMTMENT USE ONLY AppllCtllOn Accepted By Dne Grow Impm lon BY Det. Pimp Impmtlon By Dtle Deehmtlon 1'.P.11.n B //' l DNe Commentr: E"( /'W r (N� ✓�/ ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE P6,MITISERVICE REQUEST NUMBER INVOICE 50 2-3 / l 3