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APPLICATION FOR WELUPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION j 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 POR-REFUROA/LE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CBRIpMLB M Mproca1B) APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAFFER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN/ ZIS W- lftikV � ��'V`(,E+ CrrY`•."p`-' I (' PARCEL SIZE/APNf ray p 1�J�y OWNER.NAME �)M1� ItI�AY \1 C,�`\`tiI•-/\ A..S ZIS WI_MAW A STi �l�Qe�'� PHONE I✓L C(Q-3-( cD CONTRACTOR �'1,1�c 1/^^�� Q l\ AADORES.It 'T LQUNL PJVA.3i)I" LACI -7�-�^ (J PHONE/ 'J T-1-Z-ZZ I SUB CONTRACTOR V Vj 61-f Vtln ADDRESS P-�.A�'><51, ie Uoyo k.LIC/ T/�� • PHONE 9 TYPE OF WELUPUMP: NEW WELL ❑REPLACEMENT WELL MONNTONRa WELL I3_ ❑OTHER 11 INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL/ J ❑New❑R.P•4 H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O HYPE OF RUMP) ❑OVf-0FBERVICE WELL Cl GEOPNY6ICAL WELL I ❑ 801E BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q ,)�`(-1 A 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION ()" DIA.OF CONDUCTOR CASINO AV P/ 0 ❑DOMESTK:IPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASMO/STEELIPM A.OF WELL CASINO c-( Z D ❑PU UC,`MULRCIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION Jl-•1 � R ❑IRISGATION/AG ❑OTHER GROUT SEAL lN6TALLEvQ BY `,ATF-L+AL 1' GROUT BRAND NAME Or�IJ+< l7L"Lf�"w E �"T MONITORING I•y'� GROUT SEAL PUMPED:JO Yr ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yr 5 APPROX.DEPTH • LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTR ICTIONIDIRLING METHOD:MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE%BY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORM WALL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND REGULATION.OF THE SAN JOAQUINCOUNTY.10ME OWNER OR LICENSED AGENT'.SIGNATURE CERTIFIER THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED.1 SNALL NOT EMPLOY PERSONS SUBJECT TO WORXMAM'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUB-CONTIUCTMG 61GNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEWAR 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAW.OF CALIFORNIA..''\THE APPLICANT MUST�CALL �S�4 HOURS III AVVVANCE FOR ALL REOU11iD IINNSjKCTONS ATIINWI 409--3V422.COMPLETE DRAWING AT LOWER AREA PROVIDED. p BISeM% Y.& Tttl• 1`�/l GiN.(.YI //1l!/1'1/Ctili O.1•� �i O PLOT PLAN M.•.v ro 8.0.1 Bad• 'to 1.NAMES OF STREFT8 OR ROADS NEAREST TO OR SOUND"THE PROPERTY. S.LOCATION OF HOUSESEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF BEWAGE DISPOSAL SYSTEMS. O.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH A.PATIOS,DRIVEWAYS,AMD WALK.. ON THE PROPERTY OR ADJONIN G PROPERTY. � ' o s 2 0 0 - a P n I Ww / Q _ 00 � s /i 00 NlYM3015 y 3nN3nti isnool DEPAR ENTUSEONLY q AppF-II oAr7bd BY Grein Irr.Paetbn BT OH• Porn,1--lee BY D- 0-111.11-1—0-BY O.4 C-- ACCOUNTING emm -ACCOUNTING ONLY: ADI FAC! PE CODES FEE INFO AMOUR REMITTED CHECK//CAIN RECEIVED SY OATS POMATMERVICE REQUEST NUMBER INVOICE 0-11' 0� Pub 4BBtth Serv.-Enviro.173(1/97)