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+ APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SE t ES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA SIMM- 88 {205 488.3420 O A�,;7� IIOIf•REFDRDABIE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � (Complete In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK O£BCRIBED,THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-111 S.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION.JOB ADDRESSOR APNI+ � I� ^/v„ CITY 'i p 7PPAACEL 812E/APN/ OWNER'S NAME H IC ADDRESS ill• /S�V� ONE P CONTRACTOR � Pgo7 ADDRESSLICI.�'�Bt�'/P�- -P1iON SUB CONTRACTOR (� ADDRESS LIC+<.s�.�,. 10ONE �. P TYPE OF WELLMLIMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL 0 4: - ❑ OTHER Ir ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CR088-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Repel, H.P, DEPTH PUMP SET FT. FIRST WATER LEVEL d (TYPE OF PUMPI ❑ DVT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL s. ❑ SOIL 80RTNG ❑DESTRUCTION. i INTENDED UBE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INbUBTRIAL ❑OPEN BOTTOM DPA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO /O D ❑ DOMESTIC/PRIVATE ltl RRAVEL PACK181IE TYPE OF CABINOISTEELIPVC �G DIA.OF WELL CA9tN0 yr D� ❑ PUBLICtMUNICIPAL ❑DRIVEN DEPTH OF OI1011T SEAL ,-C SPECIFICATION_ SCe•r� *U __ R, t❑�I IRRIGATIONIAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E y IEtI,MONITORING -GROUT SEAL PUMPED: W Vee ❑Ne CONCRETE PEDESTAL SY DRILLER:❑Yw ❑Ne S. I APPROX.DEPTLOCKING CHESTER BOXMTOVE PIPE e—S d ' H � PROPOSED CONSTRUCTIONIUMLLD:NO METHOMUD VOTARY AIR'ROTARY AUGERr•�_CABLE OTHER P jd ii 1 HE9E8Y CERTIFY THAT I HAVE PREPARED TH18 APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANC REGULATIONS OF THE BAN JOAQUIN COUNTY. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICI THIS PERMIT IS ISSUED,1 SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION)AWB OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTPFIEI SONS SUBJECT TO WDRIONAN'S COMPENSATION LAVYB Ol THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH 11418 PERMIT 18 ISSUED.1 SHALL EMPLOY PER CALIFORNIA.'p APPU NT MUS CA=HOCIRB VANCE FOR ALL REQUIRED INSPECTIONS AT 12011 4ee-S422. COMPLETE DRAWING AT LOWER AREA PROVIDED. SI ned X TIOG 4 �= r/ti)S f i n .bete -J PLOT PLAN Itkew to Seale1"s, 'to 1. NAMES OF STREETS OR ROA 8 NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF T14E PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENStON0 OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. BTHUCTUREB,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERLY OR ADJOINING PROPERTY. N } 799 WM J HUNTER&ASSOCIATES210 / �� f 2220 LOMA VISTA DR(9 16)972 7941 �G Zz 19 Q� 11-35/1523 (((( SACRAMENTO,CA 95625 < PAY TO THE $ ORDER D O L L A R S � nb [}�Bank of America CL(strniler itice Arden-Morse Branch#0523 1 9 9 2 f 3101 Arden Way Sacra a lo,C 958 1916}373.6920 Si7 LUOQ�! MEMO — v -.- ;,. '�ppp3-5'R1;0.7�1_q�IIIO_5 2-39-,16 SIR-2G 1 _ .......................: DEPARTMENT USE ONLY T Date -51(0N--011 APPllcetien Accepted BY I Orevt Inspection BY Date Pump 1nsPectlen By Oela Deetruetlen Inspection By bate I Comments: - r I ACCOUNTING ONLY: AIDS FACS 4. ► ' I FP,, DES FEE INFO AMOUNT REMITTED CHECK/!CASH RECQVED By DATE PERMtTISERVICE REOIJEST UMBER INVOICE