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AFFLICATION FOR WEL IPUMP PERMIT SAN JOAQUIN COUNTY PUB IC HEALTH SFPr"' *S ENVIRONMENTAL HEA TH DIVISION : PA BbkU% 304 EAST WEBER A UE, STOCKTON. CA SIM01-8 1209) 468-3 Za i NON-REFUNDABLE PERMIT EXPIRES YEAR FROM DATE ISSUED (Complete In Tr lkate) APPLICATION IS HERE BY MADE TO THE SAN JOAUUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOP IR INSTALL THE WORK DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT T fLE.E•'CI4FT A 9-1 115.3 AND THE STANDARDS OF SAN�JOAOUI COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMSION. JOB ADDRESSOR APNO 7 G/I 1'• C �'� PARCEL SIZEIAPN/ Al-VOWN !/NOCA2 �/�fJ/CA;r 7 a/J } /7 y �fnl 427 ER'8 NAME 1'A, /'� ADDRESSt16, �W L,l�-JVSI(I� �/C.�.ii�'� PHONE /� ��j/"/� ��p CONTRACTOR �%�tjL'y /�,��,r�Iy/yt / (3/��{/� ADDREV ~ / / IJCI /F/— PHONE/ 7rY�-7%BUBCOFITRACTPR IVO(. �//[r!i' �� N�+ ADDR /� 7�t) J !/1j/4LIC/ti�7 -7 • TYPE OF WELIJPUMP: NEIN WELL ❑ REPLACEMENT WELL MONITORING WEILLI 13OTHER XNSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑Now❑Repair H.P. DEPTH PUMP SET FT, [TYPE OF PUMP) FIRST WATER LEVEL d ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSIC WELL ❑ SOIL BORING s ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATI NS �� pyt�f^`� A © INDUSTRIAL BOTTOM DIA.OF WELL EXCAVATION DIA.Of CONDUCTOR CARING p ❑ DOMESTICIPRSVATE 11]�GRAVEL PACKIBRE TYPE OF CASINGMTEEL/PVC G DIA.OF WELL CASING �� D ❑ PUBLICIMUNICIPAL f❑`DRIVEN DEPTH OF GROUT SEAL SPECIFICATION A� ,i,-T R ElKI IIRRIGATNIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME &f4fiG1E/Uf E '']LI MONITORING ;/J ��,, GROUT SEAL PUMPED: ❑Y ❑No CONCRETE PEOESTAL BY DWLLER:❑YM Na S. APPROX.DEPTH ®YJ } LOCKING CHESTS BOX/STOVEPIPE 8 PROPOSED CONSTRUCTIONMNtUNO METHOD: MUD ROTARY AIR ROTARY AUGER V CABLE OTHER I HMSY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE 1N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND 1 REGULATIONS OF THE SAN JOAQUIN COUNT"'. HOME OWNER OR LICENSED AGENT'S SIGNATURE CEFTI IFIES THE FOLLOWING; 'I CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRINO OR SUB-CONTRACTING SIONATURE CERTIFIES THE FOLLO : 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT!S ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA THE APPLICANT ST 24 IN ANCE�F�JORR ALL REQUVIIEP INSPECTIONS ALT f�F.ASS.7422. COMPLETE DRAWING AT LOWER AREA PROVIDED, (� /J - Z/7w r. Date / 21 � PLOT PLAN[Draw to Sealal Sulo 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 EXISTING-AND PROPOSED , 6.'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, a .. k. ... .....f... ...-.,.. --:-... .. .. .. .. ., E I w�.. --�.� .ti.r.��-.�=w,r. ` N DEPARTMENT USE ONLY --!' Applleetlen Aaoepted By r ![F Date Area S Grout-Inspection By- Date Pump Inspection By Data Destruction Inspection By - Date Comments: ( .-�� x— ' vC/ ACCOUNTING ONLY; AID/ ` FACT d PE CODES FEE INFO AMOUNT REMITTED CHECKIICASH RECEIVED BY DATE PERMITISBiVICIE REQUEST NUMSER INVOICE {