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_ r APPLICATION FOR WELLPPUMP PERMIT BMX SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION r HE ' P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA`;52 ;1# THEA! 1209).469-3420 RVXX NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSIAD P{t 5 1CempinLf In Triplicalel ! APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT To CONSTRUCT AND1014 tNSTALL THE WORK DESCRIBED.TINS APPLICATION IS MADE 1N COMPLIANCE W"If SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3�ANND,TH`E STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMSION. JOB ADDRESSIORr/A"yF/'+N/I��i ya ,_v �0c.M Yi� I`�."y�3. _DTV YL�'1L�L Shy 4 L SIZEIAPNO d OWNER'S NAME ` 'TT^� AOOR> 8 y��v+ f`T ZIP CONTRACTO IK'N VY _ _,-OO�R6 "' '•"'�'' 1 �1 ,V LICE��,PHONE f %�T -J4vc;06z CIO, SUB CONTRACTOR ADORF.SS LICE PHONE f TYPE OF WELLIPUMP- ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL f ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F .� i ❑New❑Repell N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O IT YT-E OF PUMP) - ___,��,,.r „ ,-,. .. - _:-. ^"�^'-0-OUT-oP-LEnvtCE'WEL4: ❑-O EOP1iY15ICAUWEL1'/ � � LY SOIL SORING: ❑DESTRUCTION: 1NTEN4E0 USE TYPE OF WELL CO NSTRUC IION dPECIFICATI�NS _ A - TI ❑ INDUSTRIAL ❑OPEN ROTTOM DtA.OF WELL EXCAVATION Z DIA.OF CONDUCTOR CASINO O I ❑ oomEsiricmRIVATE 1❑--�,GRAVEL PACKISIYE TYPE OF CASINGISTEEUPVC DIA,OF WELL CASINO A ❑ PUBLICIMUNICIPAL LMMVEN DEPT I I OF GROUT SEAL SPECIFICATION, �XrT�7`Y\�� R El I GATIONIAO ❑OTHER GROUT SEAL INSTALLED BYL LI ��-Lr�' 1 IAL _.- GROUT BRANO NAME, GC!\/{�G^� E MDNITOINNO 1 GROUT SEAL PUMPED: ❑YY- N. CONCRETE PEP E FGTAL BY DRILLER:❑Y" 1:1 No S APPROX.DEPTH 2� w LOCKING CHESTER SOXISTOVE PIPE f PROPOSED CONSTnUCTIONIDRILLINO METHOD; MUD ROTARY. AIR ROTARY AUGER CABLE OTHER I HE4ERY CERTIFY THAT I NAVE PREPARED THIS APPLICATION AND THAT THE WIEOTK WALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,ANO RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERrORMANCE OF THE WORK FOR WHICH THIS PERMIT 1918SUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFOIINIA,' CONTRACTOR'S HIRING OR SUB-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOTK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE�Ak'T MUST IGtk�L}24 NN]OUR6 1M ADVANCE FOR ALL REOUi1Eb INSPECTIONS AT 120214004423. COMPLETE DRAWING AT LOWER AREA nePROVID D, /��7 7 Slgd X A VAVI•\r � RA PLOT PLAN fbrww!.Scetel S.-le 'to I, NAMES OF STREETS On ROADS NEAREST TO OR BOUNDING TNF PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PA01PERTY,GIVING DIMENSIONS AND NO}TTIT DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. , 3. DIMENSIONED OUTLINF..B ANO LOCATION OF ALL EXISTING AND PnOPORED S. LOCATION OF WELLS WITHIN IIAOIUS OF ONE ITUNDREb FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. - ✓a;e,rz, r .... . ...... .:. :.. ...... :. . . ... .. . .......... _... :. v - - � ' ... ... .... .. DEPAATMFNT USE ONLY "-. �.�.•ley�p'-.+... _ [[. -kk jApPSeellen Acoepled 8YU/�� _f bale [ A,. GIM I-P.ctlan by L_" ` Dwte Ptxnp Imp.crlan 9y Owle t' �:; DeaUneticn tn.peelton BY beie 1 co—et'w T E ACCOUNTING ONLY; AID# FAGf i f;i PE CObER FEEINFO AMOUNT REMITTED CII. Kf ASN REGrIVEO BY DATE PENNITISERVICE REOUEBT Nl1NIBER INVOICE Pub.Health Serv.-aviro.173(3196) 4