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{ APPLICATION FOR WELUPUMP PERMITCE F 0,E�j V E ED SAN JOAOUIN COUNTY PUBLIC HEALTH SERVI ENVIRONMENTAL HEALTH DIVISION FEB 01 1999 384 EAST WEBER AVENUE,STOCKTON, CA 95202 (209) 468-3420 rENVIRONMENTRL HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PERMIT / SERVICES (Cemplsts III 711pli"16) j APPLICATION 19 04E BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WMI SAN JOAQUEN COUNTY DEVELOPMENT TME.CHAPTER 9--1118.3 AHD S � I THE GTANDARDS OF SAN JOAOUIN COUNTYPU//B�� CHEALTH�B}ERsVICE8,ENVNMENTAL`HEALTH OMB`IOJN-6. TVCT \I,r OYmo ' PAARCELBIIZFJAPNf'2 07-0JOB ADORE8810R APNf J OWNER'S NAME Rkl1SelGY i `` O1/ ADDRESB'2 3 9 CONTRACTOR G'ti 111(Y0111" t4� ADOM003-495her,+s N4co ruC.(083�65 PHONE,-44Z' O ; SUS CONTRACTOR ADDAE86 { S�r 1 h 9 s 1 L 5 --If� RHONE f TYPE OFWELLIPUMPI 1:1 NEW WELL C3 REPLACEMENT 11REPLACEMENT WMoNrTORING WELL f ❑ OTHHER �., ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLf J ❑Naw❑Rapsir H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O EIYPE Of RJMP1 LL ❑ OUT-0FSERVICE WELL ❑ GEOPHYSICAL WELL 1 80IL BOMNO Z ��d pG R a ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS R P A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION I �1 G�S _ DIA,OF CONDUCTOR CASINOW„ A ❑ DOMESTICIPWVATE ❑GRAVEL PACKMZE TYPE OF CASINO/STEEL/PVC N eN e. DIA_OF WE � WELL CASINO N D ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL Z S Feet __ SPECIFICATION 14 A R �11 �/Jtl6ATIONIAO ❑OTHER GROUT SEAL INSTALLED BY rC t Q GROUT BRAND NAME e C e til+441. F ' Lp MOMTORINO GROUT BEAL PIMPED: 13 Yaa Ne CONCRETE PEDESTAL BY Di um❑Yr RC S AP X.DEP?N Z S_Feet LOCKING CHESTER BOXMTOVE PIPE [' S PROPOSED CONSTMICTIONIDI unta METHOD,. MUD ROTARY AIR ROTARY AUGER CABLE OTHER Ire 4 robe irec - Ws I HM8Y CERTIFY THAT I HAVE PREPARED TMS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDNANCEB.STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AOENT'8 SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT W THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IN ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAH'B COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S"I'mm OR OUB-CONTRACTING BKRNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERM IS ISSUED,H SHALL EMPLOY PERSONS SUBJECT TO WADIUMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS III ADVANCE FOR ALL PROUMM I/N�SPECTIONSr AT 12091 4*84423. COMPETE DRAWING AT LOWER AREA PROVIDED. �L BWmd X TBI. C 01}S IA lt4 11-t o.c. '1-! 11 .9 J TO-S F-1pq1H R A 1%4 4 PLOT PLAN Meow to Social Basi. He 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HHOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUHE OF THE PROPERTY.GIVM DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTLINF.B AND LOCATION Of ALL EXISTING AND PROPOSEO S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. 8TRUCTUREB.INCLUDING COVERED AREAS BIRCH AB PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOOMM PROPERTY. �-/�/ DfIARTMl71T USE ONLY ^ G� Applla.11en Aaaepted BY_. L �L ,�.,,..^ ... Dal.�__9 1 M.a Orout InapeeOwn BY D.t. P\.np Inspeallat%BY Dote beatnlellon tnapectlen BY Dale Cemmaxa: Ll ��5 1 4J0 1 3// ACCOUNTING ONLY; AIOf FACT PE CODES FEE INFO AMOUNT REMITTED CHECKf/CASH RECEIVED BY DATE PERMITIBERVICE REQUEST NUNBER INVOICE 41 Pub Health Serv.-Erlviro.173(1197)