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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC 14EALTH SERV..iS ENVIRONMENTAL HEALTH DIVISION NNEI PO. BOX 388. 304 EAST WESER AVENUE:, STOCKI'ON, CA 95201,388 (209) 488-3420 NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED iCompiats IR Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THI ANCE WITH SA JOAGUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,EN ME H TH OIVI N. T J�� f� r _ 0A �- JOB ADOAE68/0R A/PN/ 2 I n � 1L /`� I/f�B S CITY zo /�` PARCEL SIZEIAPN/ { OWNER'S NAME C.� "/V,S !' ADDRESS �Q /�/ Y PHONE 13 6 F—"L /!)J CONTRACTOR I�/j/ (��O S s - _ ADDRESS/ J r301 17 7 �"Zoy UCI 327715 PHONE f�j Y�7�- SUR CONTRACTOR ADDRESS LIC# PHONE# TYPE OF WELLIPUMP: 9��INnALLATMN WELL REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER k ❑ WEL�SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I FP �1�FMeuv❑RepaIr H.P. A DEPTH PUMP SET FT. FIRST WATER LEVEL I {TYPE OF PUMPI � ❑ OUT-OF•SERVICE WELL ❑ GEOPHY ICAL WELL R ❑ SOIL BORING { - a b'DDESTRUCTION: �] �✓ ,.�Y. Lel•. - ��.L +.. 1 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ,❑.� INDUSTRIAL �❑�/OOPEN BOTTOM DIA.OF WELL EXCAVATION�Z- _-_ DIA.OF CONDUCTOR CASINO n Ud mESTIC/PRIVATE lkORAVEL PACKISIZE TYPE OF CASINGISTEELIPVC /�'�� T..-- OIA.OF WELL CASINO 95 1 ❑ PUSUCIMUNICIPAL ❑DRIVEN DEPTH OF OROUr SEAL �a� �G SPECIFICATION — yJ-' — . A ❑ IRAIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY ti (74 GROUT BRAND NAME <::f m C E, ❑ MONITORING GROUT SEAL PUMPED: EXL ❑No CONCRETE PEDESTAL BY DRILLER: r ❑No $ APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE 3 PROPOSED CONSTRUCTIONIDRILLING METHOD; MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE9EBY 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 ANi REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHIG THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR-8 HIRING OR SUBCONTRACTING SIGNATURE CERTIFIE THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS O CALIFORNIA.' THE AP CAN MUST CALL 24 HOURS 1N ADVANCE FOR ALL REGtXRED INSPECTIONS AT 12051 4AD3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X Title �t.!// n-- bets I f 2`� — PLOT PLAN Mraw to Sahel Sole •to ' 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNOING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED f 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. f a. 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 AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. _ . Dpigam.... ....: ,... .. :... ....... '....... �„eo>� � X�L� _ .. LNVIRONMEIVTAL:HEALTH:_ .... :..PERMIT/SERI!ICES IL ..DEPARTMENT USE ONLY Applieetlon Aaaepted By e Ares 7-1 Grout Impaction By iG Dai - y �J �e C Pump Impectlon 0 .�._c� # Data beotrucllon Impeatian By Dale P 00;L41 ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED . HECK CASH RECEIVED BY DATEBEgyCE��R``EG�U7EBT N ER INVOICEvv �yp 1200 �r s2o0v o a 3 a 90 11-3 aSRo-o f5o0,2-3-`4C/-j- .