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APPLICATION FOR WELUPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICnmpMb In TRIpRentE1 APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPUCATION 18 MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND HE STANDARDS OF SAN JOAOUIH COU r/N9 IC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION, JOB ADORESSMR APL C H P✓' _CITY �/'�)1� !J On 'J PARCEL SIZE/AMI fj OWNER'SNAME LE 1 7 -� ADDRESS V[` /,1/ '-3X I/ �SYE/7k�_ PHONE CONTRACTOR l l l l /T l� /1,/ ,,// Sl �R10NE 17 ZZ�/SZ✓ I ADDRESS SUB CONTRACTOR ADI I OHI UC/ M40NE I EYP OF MLL/R1MP; ❑ HEW WELL ❑ REPLACEMEW WELL ❑ MONITORING WELL I IK.THER ❑ INSTAI.UTION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑New❑R1eNr "'P. DEPTH RUMP SET FT. FIRST WATER LEVEL O HYPE OF PUMPI ❑ DVT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL l ❑ BOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A J1 ❑ INW6TMAl ��❑OPEN BOTTOM DIA.OF WELL EXCAVATION ��i DIA.OF CONDUCTOR CABIN(y D I�MESTIC T VATE d;LQVAWL PACK/SIZE TYPE OF CASINO/STEEIJPVC IJ E�� DIA.OF WELL CASING / O ❑ PUBUUC/MUNICIPAL ❑DRIVEN DEPTH OF GROW SEAL 1^ 213• SPECIFICATION //''� R 11IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY I GROUT BRAND NAMED V f E ❑ MONITORING GROUT SEAL MNRVO: / N. CONCRETE PEDESTALS NLLER S /�/ — APP110%.DEPTH / JV LOCKING CHESTER BO%ISTOVE PP 5 PROPOSED CON6FNM ION/ONLUNO METHOD: MUD ROTARY_AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APIUCATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAMIN COUNTY. NOME OWNER OR LICENSED AGEW'S SIGNATURE CERTIFIES THE FOLLOWING:'I CEATFY THAT IN THE PERORAANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORPMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY MESONS SUBJECT TO W'OAAAAN'S COMPENSATION LAWS OF CALIFORNIA.• TINE ASE/IC�ANTT MUOTCAAeLL_E4 HOURS IN ADVANCE FOR ALL REQUIRED UNNII CTIQI AT CMH 4SSAA]3. COMPLETE DRAWING AT LOWER AREA PROVIDE/D. G B1VrodX 11r`Ei / 'I L'✓rLN W/� TIO. LJY L1/r0✓� D.1. PLOT PLAN I —I.Sc N.I BeN. I. I NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. e. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.GfV DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OLUMFS AND LOCATION OF ALL EXISTING AND PROPOSED E. LOCATION OF V2E1.18 WTPIIN RADIUS OF ONE HUNDRED FIFTY P. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,ONVEWAVS.AND WAIAB. ON THE PROPERTY OR ADJOINM PROMRTY, IAYM F- l r SEP 2ti 1998 Y •-r c S r \� 461� lyklle F::Fe P A / �/ DEPAATMMT USE ONLY C AnnunNlen A.c.pl.d Br /�"" D.I.) !`y'S Aru / mI. c.T Knn 1 q 1p anQ. w ACCOUNTING OHM AID/ FACE or PE CODES FEE INFO A KHPIT REMITTED HEC SMASH RECEIVED by DATE PDWITISERVICE REGIIEST NUMBER INVOICE LI__H C_.A— .YG,.,GT,