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APPLICATION FOR WELLIPUMP PERMFti/ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete M Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDAR INSTALL THE WORK DESCRIBED.THIS APPLICATION 15 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT} � `TITLE.CHAPTER 9-1115.33 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. �[ JOB ADDRESOMR APNI 7 S L V v- CITY ]/%E PARCEL SIZEJAPN/ Ch'C 1 r OWNER'S NAME % `1\ R. ADDRESS i :nk. I ev'�JS[., ONE♦ �ry CONTRACTOR L ' Dt-1, 1 ADURE86.jLqg S I' UC� I� _-PHONE f _/ 'a SUB CONTRACTOR ADDRESS UC/ RHONE/ TYPE OF WELLIPUMP: ( UXWW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CM86-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J, ❑N.❑R .lr H.P. DEPTH RUMP BET_". FIRST WATER LEVEL (TYPE OF PUMPI y®� ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ BOIL BORING ❑DESTRUCTION' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL -�JT❑'��O� NVPEN BOTTOM DIA.OF WELL EXCAVATION ^� _ DIA.OF CONDUCTOR CASING 11DOMESTIC/PRIVATEATE L¢sgRAVEL PACKISIZE TYPE OF CASINGISTEELCDIA.OF WELL CASING f�T— ��T ❑TJ( PLMUC/MUNICIPAL [I DRIVEN DEPTH OF GROUT SEAL SPECIFICATION dZ. iPAIGATxaN/AG ❑OTHER GROUT SEAL INSTALLED nBIY GROUP BRAND NAME ESI ❑ MONITORING � /�/I /�J 1 GROUT SEAL PUMPED: r 11 N. CONCRETE PEDESTAL BY FILLER:11Y.�y S APPROX.DEPTH -T'[l M r LFL /I LOCKING CHESTER SOXWOVE RPE S PROPOSED CONSTRUCTIONJDRIWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE NAR(WALL BE DONE M ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE IAM,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERTORNIANCE OF THE WOR(FOR WHICH THIS PERMIT 16 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENeATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUStONTRACTRIG SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMrt IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPFIISATION LAWS OF CALIFORNIA.' THE APPMCANT MUST CAL1, (,(GURe IN ADVANCE FOR ALL REQUIRED INe\PFCT10NS AT 12HN)4660423. COMPLETE DRAWING AT LOWER AREA PROVIDED. 61o�sa x / r, /G9.NS TDI. 1� H ( I I P.,I Om. PLOT PAN IOrsa 1.So.I.J 6c.H Io 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF MUSE 6EWAGE DIBPOBAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY R. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING FRCPERTY. 71 E 1 IAF al � •a; . � . r, lc �i n e Ivi n Y O 9 199i -- - DEPARTMENT USE ONLY �` - HFgI TN APPB..tbn A.reM6 By D.R. Mr 1 q J G..ut hnp.FHl011 BY '� � T� PMnO In.Pe.tlon BY OMs Dwo-mtlen hwP flan BY D.t. c.mm.nR.: n l— - 6 _" 4 In. . MOILIf, 4,4 —� CQm.L — - Ila a ACCOUNTING ONLY; AID/ FACE 1ti(ti -T Kc� PE Coon FEE INFO AMOUNT REMITTED I CHECK CASH I RECEIVED BY DATE PERMIT/SERVICE RFGMT NUMBER INVOICE If