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APPLICATION FOR WEUIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9SMi-M (2091469-3420 NON•MIFUNDAts E PERMIT EXPIRES 1i TEAR F%QM DATE ISSUED ICa"Ist6 M TrIp als} A►RICATION M HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DEOCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE v4rm$A JOAOUIN COUN?�TSSY^DEVELOPMENT TrTLF,CHAPTER 9-1115.3 AND THE STANDARDS OF am JOADUIN COUNTY PUBLIC H IRO ALTH SERVICES,ENVIRONMENTAL HEALTH DPASION. JOA ADORE9W 4PWl CITY PARCEL B12E/AFWf �j r/ OWNER•6 HA/,E�� ADDRESS U"h-I. F'F.w.23,7- !_ VC7 CONTRACTORNI" C r ADDRESS f ff5'/Ql^fil SUB CONTRACTOq AbONSS LICE PHONE If TYPE OF YAU^MP: WELL ❑ REPLACEMENT WELL ❑ MON"OWNO WELL I ❑ OTHER ❑ 1NSTALi ATION ❑ WELL SYSTEM REPAIR ❑ CADSB-CONNECT REPAIR ❑ VAPOR EXTAACTION WELL I ❑New❑R,wl, H.P. DEPTH PUMP SET FT. r F N WATER LEVEL 1 (TYPE OF PUMPI N �j 1j/ ❑ OUT-0E-SERVICE WEIR IL❑ OEOPHYSICAL WELL I SOa01YN0 419 ❑DE SITIUCTION! lify USE 7YPEOF Of= CONSTRUCTION S IFICATIONA A �� RI ❑ INDUSTRIAL ,,��1-3 OPEN SOTTDM DIA,OF WELL EXCAVATION I DIA.OF CONDUCTOR CASINO p ��Cf� NIFSTICRVATE L' a RAVEL PACK/SIZETYPE OF CASINOISTEEUPVC DIA.OF WELL CAGING _ L ❑ PUBLICMA"CIPAL ❑DRIVEN DEPTH OF(MUT SEAL SPECIFICATION R ❑ IlIWOATKIN/AG ❑OTHER GROUT SEAL INSTALLED RY N / _ DRDVT BRAND NAWE E U MONrTORIHO / f r GROUT SEAL PUMPEDI M.. ❑Ne CONCAETE PEDETTAL 6V LLEFL•❑Y. Ku S APRROX•DWTH_ VG LOCKING CHESTER BOXITTOVE PIPE S PROPOSED CONS TRUC TPOR/G116WNG METHOD- MUD ROTARY AIR ROTARY AUDER_ CAKE OTFE1_- I HE9EBY CERTIFY THAT 1 NAVE PREPAEO THIS APPLICATION AND THAT THE WORK WILL GE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS-AND RULEG AN REGULATIONS OF THE GAN JOAOUIN COUNTY. HOME OWNER OR UCEYIGED ADENT'B BIONATLRIE CERRIFIES THE F-OLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOPK FOR WHIC THIS PERMIT 18 ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WOORMAN'S COMPENSATION LAWS OF CANJFOWMA.' CONTRACTOR'S HIRING OR OUB-CONTRACTING MONATURE CERTFIE THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERM"16 LBSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WCOMMAN'S COMPOMATOR LAWS O CALIFORNIA.' THE APPLICANT MUST CALL Z4 HOURS IN ADVANCE Frig AL`.REDUVIID IN6PWn0 AT 12DI1 4Se-S423. COMPLETE DRAWING AT LOWER AREA PROVIDED. I�NSIBn.d k (C �• y L(l�y(i(�(il� TIIIe ►` (. Det.16�2 __ �,LI PLOT RAN GOraw to Beal,$Seale le 1. NAMES OF STIVLTS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE OISPOM SYSTEM OR RDPOBE'D 2. OUTLINE OF THE PROPERTY,GIVING DI FNBIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMEHRIOHED OUTUNF6 AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WEL"%WTHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS, AND WALKa. ON THE PROPERTY OR ADJOINING PROPERTY. G .........> . Y' L y ' O m lYE►MTMETIT USE ONLY Appllca++sn Aee.pttl By. Llata /� G,e1A"pecllen BY�i��.O DNs 1 ~I i~�P4i p 4MPaetlen By not. Dmt,mtlen b.pevtLen B__yrr I"./J.u. �i L't! ! Ai, n',� '/ ! at. Cemment/:S7Cw(j'T d N I I I No QA\.j 1 T J o+� +ln r s r,,r✓vt' ACCOUNTING ONLY: AID/ FACT ►L CODES FEE INPO AMOUNT REPATTEb CHECKIKAIN RECEIVED SY DATE PIRMT16L9TVICE REO In INVOtCE 43�+� 1�0 i g� .Oct f S o o3a,8 0 0 �P 1 5 rQrO'a O 9 p 3 a$ It�`a