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- APPLICATION FORMLLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENY11IONMENTALIH61TH DIVISION P'0 BOX 388, 445 N.SAN JOAOUINxST,STOCKTON,CA 96251-380 12091469-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM OATr matt— ` APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT a TIIpFICiiij JOAOVIN COUNTY OEVEiOPLMENT TTTLF,CHAPTER 9-7115.3 AND THE STANOARDS OF BAN JOANOVIN COUNTY PUBLIC HEALTH"RWRTALL THE WORK LSE/MCES.NENYIRONMFNTALIS rHEALTH a MADE'DIVISION. E 1 BAN .� JOB ADORESWORAPN/ I Lab 5 ORp I cirY STOCk-ToPJ - L y, ` PARCEL SIZEMAPN/ OWNER'S NAMET�l/r�-Cpyr_�'/G7 A FV ADORERS ! f1 L, 6 SOI p CONTRACTOR�S'"�^��JC� SU�U(�Zr 'V� - �i 7 7 �L U� 141,O6-To ( PION�E��.+p[�d9y)-�5it1q t_, ADpRE68�^-PTL 21vs1L12D lYLoOrc.&�� bp^ P/1ONE S�T-s�61- A"' T' SUS CONTRACTOR I ADDRESS,.USI PHONE/ TYPE 9P WElIR11M% ❑NEW WELL ❑REPLACEMENT WELL _ ❑MONITORING WELL/ ❑OTHER . ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CHDSSLONNECT REPAIR ❑VAPOR EXTRACTION WELL J ❑N.wY❑P—w H.P. xrnl PUMP SET^FT. FIRST WATER LEVEL RYPE OF PIM% . ❑OUT-OF.SERVICE WELL ❑OEOPHYSK:AI•WELLR z SOIL BORING 44 X ❑ITESTRUCTION• '•� .� B INTENDED Ui8 lime"WELL CON{TINCTION LFECIFICATIONi ,) s` ❑INDUSTRIAL ❑OPEN BOTTOM IXA.OF WELL EXCAVATION S Q!! pA•OF CONDUCTOR CASINO NI Yl A cz ❑OOPRE9TIC MVATIE ❑ORAVEL PACKOpZE J - OL O 6 . TYRE OF CABINO/STEELR•Vc_ N.�1. DIA.of WELL CASINO �7, D r w ❑P1BlfC/MUNK:IPAL ❑DIWEN DEPTH OF GROUT BEAt`� / •�- SPECIRCATION _-N' A `Jl ❑IRRIGATION/AO OTHER I r R -T GROUT BEAL'INSTALLEDiBiY G!"I - GROUT BRAND NAME U RN E n ` AP R O.DE NS 'ROUT SEAL PUMPFD:IKE Ysl [IN. CONCRETE PEDESTAL BY DRRLER;❑r.. 0N.-- S. - !� APPROX.OEPTNp/ LOCKING CHE{TER BOXUSTOVE RPE�II� F s PROPOSED CDN{T1IUCTIONfdfLUNO METHOD: MUD ROTARY AIR ROTA�. AUGER -CABLE OTHER I HE4EBY CERTIFY THAT HAVE PREPARED TWO APPLICATION AND THAT THE WORT(WILL BE DONE IN ACC WITH SAN JOAOVNI COUNTY ORDINANCES. STATE LAWS,AND RULE{ANO REGULATIONS OF THE BAN JOAOUN COUNTY.HOME OWNER OR LICENSED AGENT'S GM VRE CEPTFIES THE FOLLOWING:-P CERTIFY THAT IN THE PERFORMANCE OF THE WOPK POR WHICH THIS PERMIT IS IRBUED,I SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATMff LAWS OF CALIFORNIA.'CONTRACTOR'S I'IRIiV[T OR BUS-CONTRACTITU SIGNATURE CERTIFIES THE FOLLOW'"': .I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TWO PFNV7T LB ISSUED,I SHAD,EMPLOY PERSONS 21UBJECT TO WORIIIAANY COMPENSATION IAMB OF CALIFORNIA.' THE APPLICANT MyI17�AL�31 NOUN IN ADVANCE POR RLI,REOUAEO INBP[CflONB AT("OF 400.2479.COMPLETE DRAWING AT LOWER AREA%IOVID'Ey/O- (� 4 310-1 X V/VI I1/A'1'��7C/'JTL•i/� ON gE<L-IAL b(r Till. ��7I S�— Dnv 3_� 1 �-1 —I- 1, IPIAN1,NAMES OF STILEET2 OR 1IOA05 NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 1.1 41 2. OUTLINE OF THE PROPERTY,'MNG DIMENSIONS AND NORTH DIRECTloN. '• 3, DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 4TRt/CTUREB,INCLUDING COYEPIED AREAS SUCH A8 PATIOS,DRIVEWAYS.ANO WALKS. 'j S. LOCATION OF WELLS WITHIN RAOUS OF ONE HUNDRED FIFTY FT. ON THE PROPERTY OR ADJOINING rm ERTY. ' 37 .., _ C. IF . r 1 I .. i� _ I v i t � a (`i .. ..t, ..F-7 .- ..-.. .- �. - _ ..m v% Q I; ' y �I to n` 7r } 0 e 3 OWARTME}R USE ONLY 1 APPKoeIlen Aeeae141 SV.—Lr�'_tW HP'e •� ._ �� ..._.._.._ D.,e Y's a�-. Arr�- dvu'Il,.eee'Ien BY K" .^•.._D•tai�ILnv Hnwveiron Rr ••-- o.l. •AY Orl„pUpR m.Pm,h.I By P. -I D— C—.: —Cem } F ACCOUNTING ONLY; MDR FAC/ F PE CODES FEE INFO AMOUNT REMITTED CRECKRKMN RECEIVED BY "� ;PATE POWITISERYICE REQUEST NUNIBER IM MICE