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APPLICATION FOR WELUPUMP PERMIT { SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Y ` ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 WON-REFU11DAILE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICBmpI1t1 In TripRlltll APPLICATION 18 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIVR INSTALL THE WORK DESCRIBED.T1413 APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLES.CHAPTER 9-1115,3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ADOREBSIOR API!30 .:5f^yT/(g�h _ _CITY PARCEL SIZFJAPN! OWNEA'S NAME ADDRESS /f y� PHONE! ` CONTRACTOR ADDRESS I Sf�t[.7 UC�PHONE+�-- SUB CONTRACTOR AODRE88 UC! PHONE 0 TYPE OF WELtMMP: © NEW WELL ❑ REPLACEMENT WELL ❑ MONrTORING WELL s © OTHER - - ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J W itte _ ❑N ❑Roll H.P. e3lA11- DEPTH PUMPSET2gLFT. FIRST WATER LEVEL�� O ITYPE OF PUMPN - ❑ OUT10FSERVICE WELL ❑ dEOPHVSTCAt WEI.t if ❑ 8011 BORING e ❑DESTRUCTION: f INTENDED USE TYPE O ELI. CONSTRUCTION iPECIFICA IONI '4 DESTRUCTION- INTENDED Q INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION OIA.OF CONDUCTOR CASINO A DOMESTICR'WVATE ❑GRAVEL PACK/81ZE TYPE OF CASINGMTEEUPVC OtA.OF WELL CA61NO 0 © PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R i 0 IRRIGATONIAG ❑OTHER GROUT 8EAL INSTALLED BY GROUT BRAND NAME E ❑'MONITORING '2 ,L. GROUT SEAL PUMPED' 13Yee [IN, CONCRETE PEDESTAL BY DRILLER:❑Yr [IN- $ APPROX.DEPTH �J =41J LOCKING CHESTER BOXIS'TOVE PIPE s PROPOBED CONSTRUCTIONMAILUN0 METHOD: MUD ROTARY AIR ROTARY AUOER CABLE OTHER I HE9E0Y CERTIFY THAT T IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE 01 ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:Y CERTIFY THAT IN 714E PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORK MAN'/COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR IUB-CONTRACTING SKINATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PEAMNS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFOANIA.' �CALL,,";NO SCIN ADVANCE FOR ALL REQUIRED INSPTiON1 AT 120114434422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slpnad X THE T MUSTIHa _�� .__. .._ Dat. 3 a :99 PLOT PLAN m few to 8ealal Seale M I. NAMES Of ITIIEETS OR ROADS NEAREST TO OR BOUNDING 714E PROPERTY. 4, LOCATON OF HOUSE SEWAGE DISPOSAL SYSTEM OR Pidl'OSED 2. OUTLINE OF THE PROPERTY,OWING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EX19TR O AND PROPOSED I. LOCATION OF WELLS VRTWN RADIUS OF ONE HUNDRED FIFTY FT. STRt1CTURE8,INCLUDING COVERED AREAS SUCH AI PATIOS,DRIVEWAYS,AND WALKS. ON 7NE PROPERTY OR ADJOINING PROPERTY. .. .. .. ., .. i i 1 . w.:. AyM SEP 2.1 FjUFp , t_T �QRRvtfd� _H= LTH�IVfy(tlN 1 ... .. .0 -••16*PAR F`UR[)D*L.Y . . .. --z--- `'"'• _ _ --- ... Appllaatlen Avowed BY \ ` O a Ar" QQ . ON"Impaction BT vete PUMP Impeallon BT Da,a D-2lc7 Oeadnetlen Impaotlon RV Oate ACCOUNTING ONLY: AID/ FF,-- PE AGPE CODES FEE TNFO AMOUNT REMITTED GK! ASH RECEIVED BY DATE PERhMTISERVICE REQUEST NUMBER INVOICE �y 0-044 Pub Health Serv.-Enviro.173(1197)