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,APPLICATION FOR W,ELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERV) rS ENVIRONMENTAL HEALTH DIVISION PA BOX 388, 304 EAST WEBE:R;AVENUEt STOCK -ON,'CA 95201388 w. 12091 468.3420 B NON-REEFFU`NDARLE PERMIT EXPIAES 1 YEAR-FRI)i DATE ISSUED. i (Complete In TrIiantel APPLICATION IS HIM BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/ORINSTALL THE WORK DESCRIBEb.7HIS' , gPPLICATlON IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1116.3 AND THE STAND A RDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH.,S/E+RVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AODRESSIOR A `.( yy CIT{ Lli s PARCEL SREIAPNf V { OWNER'S NAME)//�K_ lam't1 /,/. I C C.(/ �-A` j P ADDRESS Sr'--r-�` .fes.,. `^PHONE f_- L CONTRACTOR !�`/7Y� .., �:+� �•.-r - ADDRESS I) '6W h t!C/ /73p f PHONE f 33 9• y7 r SUBCONTRACTOR 0 Iry-�f .� - ADDRESS UCI PHONES ' TYPE OF WELLIPUM: ❑ NEW WELL; © REPLACEMENT WELL ❑ mourroRlNG WELL X ❑ OTHER ❑ INSTALLATION WELL SYSTEM REPAIR ❑ CAOB9-CONNECT REPAIR © VAPOR EXTRACTION WELL/ S� ❑New qp Rrprlr MP.J-15—- DEPTH PUMP SET 1TYPEOF PUMPI FT. II�FlRBT WATER LEVEL p ❑ L)DEBTRUCTIDN: OUT-OT-SERVICE WELL ❑ GEOPHYSICAL WELLf ❑ BOIL-AOIGNO If ` ,1 {, INTENDED VSE TYPE OF WEU„ CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL OPEN BOTTOM DIA.Of WELL EXCAVATION - L DIA.OF CONDUCTOR CASINO p ❑ DOMESTICIPRIVATE ❑GAAVEL PACK/SIZE TYPE OF CASINO/STEELIPVC VIA,OF WELLICASING _ p ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OP GROUT BEAL SPECIFICATION I MIIRRIGATIONIAG []OTHER GROUT BEAL INSTALLED BY GROUT BRAND NAME _ F i ❑ MONITORING GROUT BEAL PUMPED: [IV. ❑No CONCRETE PEDEBTAI BY QRlLLER:❑,Yrs -❑Ne S APPROX,DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONRT1aLLING METHOD; MUD ROTARY_ r AIR ROTARY AUGER CABLE 1 OTHER_ Q I HEREBY CERTIFY THAT 1 PIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PEHFOTMAANCE OF THE WORK FOR WHICH IFI THIS PERMIT IS ISSUED,I 9I4ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB CONTRACTING SIGNATURE CERTHI THE FOLLOWING; 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS O CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOIIIRED INSPEClT_ION@ AT 12001400-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED, DFaned X TIt1e_<��d.Zl=�n Dote PLOT PLAN IDrrw_to Saolrl Scale 'to 1, NAMED OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE 018POM SYSTEM on pnopoBED 2, OUTLINE OF THE PROPERTY.G!VINO DIMENSIONS AND NORTH DIRECTION. - EXPANSION OF SEWAGE DISPO@AL"@YBTEM@. -' 3, DIMENSIONED OUTLINF,D AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, STRUCTUInEB,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ',ON THE`P.ROPERTY OR ADJOINING PROPERTY. 1 .. 1 ...... ..... .. .. .. - .. wu . 1Qj 28 - �Wl�k:f�l UIRf)iVtvlEfVT.AL V-EA i_7ra - Appllaotlon Aaaepled By OaleA,.... �- Grain Imprelten,By ' Ne Pump lnepe."lon By Dote DvdUvmtlen Inopeotlon By - Mo Cemmenlr: f 7 G IF ACCOUNTING ONLY; :AIDE FACE PE CODES FEE INFO AMOUNT REMITTED HECK CASH RECEIVED By DATE PERMITI@EliV10E R'GUEST NUMBER INVOICE Ll S " Pub.Health Serv.-Enviro.173(3196)