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tv APPLICATION FOR WELUPUMP PERMIT _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES _= ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202-'.- (209) 5202.-(209)468-3420 t =� MON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED ICSBI/ISt6 M TrtpRlst6l ' APPLICATION 18 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-1 115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH OMMON. JOB ADDRESSIOR APN# 1 I q L 44 CITY A.#A..J,4 e• A PARCEL w APN 217-246-7-/ . / J Se OWNER'S NAME C1.. � Q4-pn AdA.-ke Y' - TwW. AOORE88 9SA7 9— n.r.0 � r.,. 1 PHONE/_(.-So-1-Bsba Tato Kot/ ec•• S'#-E.i31L/ 99s CONTRACTOR CoM /I-+AJC--( - C1Q=yrt- Mir ADDIE66_Q ti�tA� yN,C.4 O�lr.<-�-+'J LICs PHONE# 4024-SSSS BUS CONTRACTOR pe*C L A/n►J Sl--4j0 1,- ADDRE66 4 L tI ` T UCl rp 3(s 111? PHONE# TYPE OF WELUPUMP. ❑ raw WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑N.❑R.P.4 H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O R YPE OF PUMP) ❑ OUT-or BwRVICE WELL ❑ GEOPHYSICAL WELL# I ij SOIL BORING B ❑DESTRUCTION. INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION OIA.OF CONDUCTOR CASIM O ❑ DOMESTICMPRIVATE ❑GRAVEL PACX MIZE TYPE OF CASINGMTEELlPVC DIA.OF WELL CASINO p ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION I ❑ IRRMATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL MMPEO: ❑Y. ❑No CONCRETE PEDESTAL SV ORK121t❑Yes ❑N. s APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE s PROPOSED CONST MTVON/DMIMG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HERESY CERTIFY THAT 1 HAVE PREPARED TH16 APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAO"COUNTY. HOME OWNER OR LICENSED AGENT'S SMNATU14E CERTIFIES THE FOLLOWING:'t CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COM►HMATION LAWNS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRIACTINO SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED.1 SHALL EMPLOY PERSONS BUBJECT TO WORK MARPS COMPMOAT20M LAWS OF CALIFORNIA.'2211A. APKWANT MUST CALL 24 URS M ADVANCE FOR ALL REOU111®111! �eTN S 1 14SSyt22. COMPLETE DRAVNNO AT LOWER AREA PROVIDED. IC`,#.Lig itvyz Bloom x Q_ nB. Aittn[GJ' 44.04 ya#Sr —Ct_.Z o t. `1 PLOT PLAN Ow—to Se.1.1 Sed. 'to I. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE 0I8MSAL SYSTEMS. 2. DIMENSIONED OUTLMF.6 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTUMB,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. 5�t. a .+� .. MSP. DEPARTMENT USE ONLY A"Mallen Aeo.Ot.d By Mme_^Cwt-- Date t ` ( M.o Gnwt Ir peetlen By Ukk l 11A!'.171/A Dot o 0 R.nP bw, tlen BY Dots be.en.etbn In.P.etson BY Ooze Cee.nerwc ACCOUNTING ONLY: ABO# FACS PE COOCA FEE INFO I AMOUNT REIWTTED CHECK#ICASH RECEIVED 6Y DATE ►9MATISE RVICE REQUEST NUMBER INVOICE