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JMPPLICATION FOR WELUPUMP PERM Q� OFr SA ENVIRONMENTAL COUNTY PUBLIC HEALTH SE PLE C gyp O ENVIRONMENTAL HEALTH DIVISION 44UU 304 EAST WEBER AVENUE, STOCKTON, CA 952 N (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compl.h In TripFK.I.) - APPLICATION IS AERP BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WORK DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIANCE WTII SAN JOAOUIN COUNTY DEVELOPMENT TRUE.CHAPTER 9-1115.3 AND THE STANDARDS pOF SAN JOAQUIN COUNTY-PUB/LIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. �1 JOB AODRESSroR APN/ - OD _ �VW'L- CITY C!'S� ,,(/J�. PARCEL SIZEIAPNJI�y�p(7—4(I1Y-7/ OWNER-8 NAME _,ez _ L/ % ADDRESS •yLCH,�.1!y1�••ti( c PHOl1"Er��T�J CONTRACTOR 1�J l Y� ., ^ C5 ADDRF66(�.�4..J W( �'••�"L1C/J PHONE/• SUB CONTRACTOR.' ONTRACTOR. �`�'�C-"' Iy AOOPE88�� iiiJJJ _,—I m/ j—`- {'n ^, TYPE OF WELUPUMP: ® NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ Tf❑�—OTHER ORE Y"� lFl_ly�S.� ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ® VAPOR EXTRACTION WELL/ J /(1114 ❑New❑R«dr N.P. DEPTH PUMP SET_ PT. FIRST WATER LEVEL O RYPE OF RIMPI ❑ OUT-0FSERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ 601E BONITO S ❑0"TRUCTICN: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION _nu 15 DIA.OF CONDUCTOR CASINO N D ❑ DOMESTIC/1'NVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/BTEEI/RVC �l'C SCIj..LC yO GIA.OF WELL CASINO / S // O ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL � n 6/ // J/ SPECIFICATION ./ R El &A IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED By CGnAack- GROUT BRAND NAME Ce W YPr/1 J-16 Pm FGh/2L✓ E 0 MONITONNO/ep(aek" GROAT SEAL PIMPED: IO Y. 11 N- CONCRETEPEDE6TALSYDRLLER:❑Yw ®Ne 5 q APPROX.DEPTH 3o/ LOCKING CHESTER BOX/STOVE RPf�VPS S PtIOPOSEO CONSFAUCTIONRMIWNO METHOD: MUD ROTAIIV AIR VOTARY AUGER_CASUE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS AT'PIICAMN MIO THAT THE WORK WM BE DONE IN ACCORDANCE WITH SM JOAOUIN COUNTY OROINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFOWANCE OF THE WOM FOR WHICH THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR Vo-co RRACTINO SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIB KRAUT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORMAN'E COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED mSFE/CTBNNSS AT 12051 IM�1S22. COMPLETE DRAWING AT LOWER AREA RIOVIDED. Titl• /V•e/'!'OT /•rQC 0•r• 5\, G\`��'L� PLOT PLAN IO.wv le 8C0•1 Bc•I• 'to U 1. NAMES OF STREETS OR ROADS NEAREST TO OR 110"NO THE RbPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR RIOPOCED 2. OUTLINE OF THE PRKIPERTY,GIVING DIMENSIONS AND NORTN DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING ANO RWPOBEO S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,ANO WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. Sv,uwC -no3 . __SrE._I003 SvE-o/y A �f J�1 svNu�E - ooy oo4/ O/S 00 6 ISP .A S v M uW - 0/ 00 7 00 �Q�lbCp 5v AA w-0/S sv R`w 0/fo of O lk O/ DFPMTMENT USE ONLY AO/J /�///�/y(]��y/// ADPPe•Ilen A«epid 8 D.1. A, 0`�U / a.ea h•P«ne,I Br D.I. P.eP Ia•P«nem er OH• De•bm/en In.r«Ileo ar ml. CemmaK• ACCDIINTND ONLY: not FAC/ �— PE COOEE FEE INFO AMOUNT REMITTED CNESXAUCASH AEC9ED V ■Y DATE P TISEOVICE REQUEST NUMBER INVOICE o w DZ 5-28 D 50 Pub.Health SEN.-Enviro.173(1/97)