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Etv .L�, � � O Z D APPLICATION FOR WELUPUMP PERMIT RE EVE SAD' 'AOUIN COUNTY PUBLIC HEALTH SES ,ES ~ �S ENVIRONMENTAL HEALTH DIVISION NOv 2 ZOO 304 EAST WEBER AVENUE, STOCKTON, CA 95202 ouNTy (209) 468-3420 SP 430poul SER\ACESS 0 MON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED Zll �N p. M NEAL (Complata In TripOcate) APPLICATION ADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOFK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. e JOB ADDRESS/On AAPNNI / [/ (jCYt-f r j Ir[�� CITY (,/4'/ ��"�L�/ PARCEL S12E/APNI OWNEn'8 NAME /,. rc'U P- �N /G F/F ADDRESS PHONE I 1)'�•�- / _ s>=30�,_ «.4-�.v:.•T JliN,lotcTDTr j!� f L'$-�L /L/ 'T ADDRESS l7 5 n p,IV if �T uCI PHONE I SUS CONTRACTOR V_L��n��*-�D r�L ADDRESS 7 tS7 Tr/._14-112-M6— UC! PHONE I �l 113,15— TYPE 3,15TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL X MONITORINO WELLS / ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAr n( � ❑ VAPOR EXTRACTION WELL I J ❑New❑Rep.lr H.P. DEPTH PUMP SET FT, /' FIRST WATER LEVEL O (TYPE OF PUMPI ❑ OUT-OF-SERVICE WILL ❑ GEOPIIYSICAL WELL I6OIL BORING S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C/ A ❑ INDUSTRIAL 11OPEN BOTTOM DIA.OF WELL EXCAVATION �n p '` DIA.OF CONDUCTOR CASINO 2-4 D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/(VC... DIA.OF WELL CASINO D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORINGI GROUT SEAL PUMPED: 1:1Yr [IN. CONCRETE PEDESTAL BY DRILLER:❑Y. []No S APPROX.DEPTH 170�J0 LOCKING CHESTER BOX/STOVE PIPE If-L S PROPOSED CONS TRUC TION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER 1 FIEREBY CERTIFY T14AT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIONATUnE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOn WIIICII 71118 PERMIT 18 ISSUED,I SIIALL NOT III OY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: CERTIFY TH 1 IE RMANCE OF THE WOPK FOR WHIC11 THIS PERMR 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' T'!j�/�/,(1`P T ALL 4 I�Ra IN ADVANCE FOR ALL REQUIRED INS-PECCTTIONS AT 12051 4&!-3423. COMPLETE DRAWING AT LOWER AREA PRO O. BlSned X J' Till. PLOT PLAN 0—to So.I.I 8a.le 'to 1. NAMES OF STREETS OR ROAD NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On 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 HUNDnED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. '.. `. OL _. . ._. ..._ ...... .....: . aw►a/a,arwt a►ae al+a• '�� (f J J