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t APPLICATION FOR WEWPUMP PER -01 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �' ENVIRONMENTAL HEALTH DIVISION ' 304 EAST WESER AVENUE, STOCKTON, CA 95202 JAN X999 (209) 468-3420 RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED (Cal+plefe In TIIplielllej F=Vir:?ii4_ 31,j-[: LT� :SA�iSE� 5 APPLICATION 19 HERE BY MACE TO 714E SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DE6CRIGEO.THIS APPLICATION IS MADE IN COMPLIANCE WIT){SAN JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1 115,3 AND THE STAHOAADS�O�FF SAN JOAMIN COUNTY }PUBLIC HEALTH SEVI RMES.ENRM ONENTAL HEALTH DIVISION. as- JOB AOOREBSIOR APN/ 7 �H CSTY_/`fes'' f1/f�1 PARCEL 81ZElAPNf J/'f'3-aZ OWNER'S NAME '/ SI61* .AOORE89 Z I-ffu�- 92,_"-✓TF>/`K1 (rf•1 F4lONE! 4f7p r7 '� ,! CONTRACTORd6y,/ (jOOL��PHO NEP i 47- e RtUB CONTRACTOR ADDRESS LICA .PHONE/ TYPE OF VVELLIPUMP• ❑ NEW WELL ❑ REPLACEMENT WELL ❑ ONRORNO WELL/ ❑ OTHER © NNSTALLATION ❑ WELL SYSTEM REPAIA 0.0ROG9-CO'NWCT REPAIR ❑ VAPOR EXTRACTION WELL I RYPE OF PVMPI J ❑N—❑RW i, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL a _ - ❑ O(Tf4F•SERVICE WELL ❑ OEDPHY8IC AL WEU.spd BOIL BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONaTAUCTION SPECIFICATION• I•4 ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL E]CCAVATION s OIA.OF CONDUCTOR CASINO AIj'. A © DOMEBTICIPWVATE ❑GRAVEL PACKI81ZE TYPE OF CASINGJSTEELlPVC V .GIA.OF WFLL CwseNG # O O ❑ P RIGATI NIAG AI DIWEH DEPTH OF GROUT SEAL. Zo 8PECIFK:ATtON r ' ❑ IRROATION/AG ❑OTHER GROUT SEAL INSTALLED BY ��yy GROU r BRAND NAME � �f E PYMONROUaNG f GROUT REAL PUMPED: ©Vws APPROTI.aFPTN ON. ��CONCRETE PEDESTAL BY ORI.LEII:Ely. Elm l9 . ZO LOCKING CHESTER BOXTOVEUDE P PRofosED CONSTRt1CT10NlDRKfUNO METFIOD: MUD RGTARY AIR ROTARY S'- AUGER CABLE OTNEA�P� I HESESY CERTIFY THAT 1 IIIAVE PFWPAFED THIS APPLICATION AND THAT THE WOPK 1MLL BE DOW IN ACCORDANCE WITH BAN JOAWN COVCOUNTY O REGULATIDN9 OF THE SAN JOAORDINANCES.STATE LAWS,AND RULES AND UN fVTY. HOME OWNER OR LICENSED AGENT•e SIGNATURE C1 TTWIE9 THE FOLLOWING:•I CERTIFY THAT IN THE PERrOFSMANCE OF THE WORK FOR WHCH TMS PERMIT IB ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP9VSATgN LAWS OF CATF+DRMA.' THE FOCONTRACTOR'S MIalIG DR BUB-CONfRACTR/G SIGNATURE CERTIFIES LI.OWNNG• CETRIFY THAT IN THE PERFORM OF THE WORK FOR VVNICH THIS PERMIT I$ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO W01114MAN•9 CIIMPE}ISATION TAWS OF CALUFOIp1 APPIIC 2 ADVANCE FOR ALL REMMI D OJSMTIDNS AATT[I20q 4es4s". COMPLETE DRAWIIIKT AT LOWER AREA TSX• D•tw PND 81p+ee X i _��R/GC+I !iFll �/ +!/ .�� f /SOT FLAN 44N• to 00•I.1 Sash - 1. NAMES OF STREETS OR ROADS NEAREST TO tRIDRVG THE PRUPERTV. _ 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLIVE OF THE PROPERTY.G1ANG pMENSIONS AND NORTH OIRECTKON. - 7. DIMENSIONED OUTLOWS AND LOCATION OF ALL EkrSTBVG AND PROPOSED - .; - EXP'ANSIDN OF SEWAGE Ol9AOSAl SYETEMB. - S. LOCATION OF WELLS VVTTMN RADIUS OF ONE HUNDRED FIFTY FT. BTRUCTVREB,INCLVDING COVERED AREAS SUCH AS PATIOS,OfEVEWAV8•AND WAIJKS. ON THE PROPERTY OR ADJOfMNO PROPERTY. i?".1 ... . .......... DEPARTMENT USE ONLT - APPIIa•Ifen AeoWsd er ' yam/ Pa•D//?—/ Grwt ImPwatbn BY 'r Dat•`� A4r�� i e Impaetbn By - O.wrnrerlett Ir.roctfen Br Drt• Ostw Ce.nnterxr ACCOUNTING ONLY: ,jc' f AC,F PE CDOES FEE INFO AMOUNT F; rrED CHECK/lCASH REC eY DATE P911IITISElFVICE RED UEDT NuNB9U INVOICE' '. t 1 'Is Pub "IS&h Serv,-Ermro.173(1157) �,i.