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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 / 1 Z NDN-REFUNDABLE PERMIT EXPIRES 1 ►EAR FRDM DATE ISSUED '� S, (Cempbb In Tr11Reviel Ar'f9_Ir•AT ION IB NFRE RY MADE TO TILE SAN JOAQUIN COUNTY Fort A PFMAIT TO CONSTRUCT AND/OR INRTAIL TIIF WORK DFSCnfRFD.Tf If@ APPLICATION OR MADE IN COMMIANCF WIT#I SAN JOAOUIN COUNTY DEVELOPMENT TITTLE,CHAPTER 9-1115.3 ANDyTilt STANDARD@ OF RAN JJOAGUIN COUNTY PURLK:11EALTH BERVICEB,ENVIRONMENTAL IMALIII DIVISION. JOB AUOnf.SA/Ort APNI_�S� v'LCIfGY,_. � �C' I& I PAnrFL R / 17F/APSJ OWNFn'S NAME A/�/SL[fi_?IV88__! /L./-✓� /`'J / AIONE CONTRACTOR AODRERS LIC/ NIONE At RUB CONTRACTOR ADDRF8R IJCI 1'lloNF.I TYPE OF WELLJPUMP• ❑ NEW WELL ❑ AF.FVICEMENT WFLL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CRORS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ,/ .,y eA V ❑N—❑R.o.h N.P. DEPTII rUMP NET FT. FIRST WATER LEVEL U YR'E OF P'VMPI O J�P. ./�,fyOUT-OF-SERVICE WELL ❑ OF.OMIYSICAL WELL I ❑ ROIL RORNO ❑DEBIMICTION! INTENDED-VSE IYPE OF WELjtCONSTRl/C TION tPECIfICAiIONS ❑ INDIISTMAL ❑OPEN NOT-Tom DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CARING n ❑ DOMEIMCR'MVATE ❑GRAVEL PACK/SIZE TYPE OF CARIMMEE1/1'vc DIA.OF WELL CARING O ❑ PVBLICIMIINICIPAL ❑DMVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ InnIn ATION/AG ❑OTHER OROI/T SFAL INSTALLED BY GROUT PRAND NAME F ❑ MONITORING GROUT BFAL PUMPED! ❑Y.. ❑Ns CONCRETE PEDESTAL NY DRILLER!❑Y« ❑N. S APPROX.Dt"H LOCKING CHESTER BOX/STOVE PIPE S MAOPORED CON8TINUCTIONMRIWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I IIF-WBY CERTIFY THAT I IIAVE PREPARED THIS AR9JCATION AND THAT TIIF WOR(WILL.BE DONE IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES,STATE LAWS,AND RAILER AND SFOULATIONB OF TILE SAN JOAOUIH COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CFRTIFIEB TIfE FOLLOWING!9 CERTIFY THAT M Tiff PERFORMANCE OF TIIF WORK FOR W/IIC11 11118 PERMIT 18 IRSUED,1 SIIALL NOT FMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S IRRNG OR SUB CONTRACTM SIONATURE CERTIr1ES TILE rOIAOWI : •1 CERTIFY THAT IN T1fE PERFORMANCE OF THE WORK Fort WHICH Title MnKgfT IS ISSUED,1 SHALL EMPLOY PERSONS NUNJECT TO WORIGNAN'S COMPFNSATIGN 1,A OF 019-dCAlfror RA.' T/IE CANT MV T CALL 21 NOUS fit ADVANCE FOR ALL REGUIRFI)INSPlICTTIOONNS}�JAt 1"001 AHJ/29. COMPLETE DRAWING AT LOWER AREA MLOVIO'F-7D,q Rlpd X l Title �� /lilt l_ D•I•�Q_'aL / / T[.—_ ►l0 IDrav to Sootel Red• •to 1. HAMER OF STREETS OR ROADS NEAREST TO OR POUNDING TIIF PrJOPERTY, 4. LOCATION OF HOURESEWAGE OIRPoSAI SYRTEM On P7RIPOSED TIL 2. OUTLIVE OF E PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF NEWAOE OISPOBAL SYSTFMB. J. DIMENSIONED OUTUNFB AND LOCATION OF ALL EXISTING AND Pnor osto S. LOCATION Or WELLS WTITBN RAMVS OF ONE IR/NonEO rlFTy n. STRUCTUrtER,INCLUOING COVERED AREAS 8UCH AS PATIOS,DRIVEWAYS,AND WALKS. ON.TFIE PROPERTY OR ADJOINING MEDPEIITY, ,c----....,..._..,.-..- IRvi► V [1 K =•�C—�=:;�—� M7'it'ta'C •11.1 J' (� as lou TW e`--- xL• r ) 10EB►f KAIIOH Of OglEp v ' / Ad• _.11llL:-L IEA • p Oedw1E ( KLL V PARCEL. I PARCEL 8 1 . 1 i F[ 1tE At•LL ISE KAL �1"'X..�)s t;,j1�j'J f..iA� �) 11[CI rCHI �lUN fl 0 g T,/. fele II II J �' � A �1{ PDT _:IItIN CAI.r1ML LM.i ltt fF1J7/11.NF 11.' rnc. 111�(I.Qerc li IVISIC.'1 GMI IAJ of Ivr `tA� Sra�� 1I2112LdIlal._` (IPU 1,l\L' i i SIIC K F TORAY i..ti •.v iutiwa 011 Aafl► u+ln IMt IT k DFP RENT VIE ONLY -- AIIpll,.Ilen Aevepled Py DAN/• ) ♦/ � Arp n:eur Im,.,nrlen NT 0 • ✓V `� DN• C Y. On.Inrellen Irwprlbn BY _Ode l ocizaw IL 74 ACCOUNTING ONLY! AID/ CACI I PE CODES TEE INro AMOUNT REMITTED CHECKIICAIN RECEIVED NY DATE PE/MITISERVICE REOUEST NUMNM INVOICE Pub Health Serv.-Enviro. 173(1/97)