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OPLICATION FOR AELL/PUMP PERM ' SAN QUIN COUNTY PUBLIC HEALTH SERvT ES P � lhc o p y a P'��y ENVIRONMENTAL HEALTH DIVISIONf ', 304 EAST WEBER AVENUE, STOCKTON, CA 95202l L J (209)458-3420 �oouN� -1� s N vIp� yQ NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED lI VV''\` (Complete In Triplleetol APPLICATION IS HERE BY MADE TO THE CAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE Nlft JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH/MR CES ENVIRONMENTAL HEALTH DIVISION. T JOBADDRESSMRAPUt Sl51 PRCY GIC AVc'iVL%E CITY PARCELSIZEJAPN/ 16"T'1410-G/ OWNEA'9NAME/, ^1iY�L%Ash/1'n/f}�GT� L�OtlleC,F ADDRESS S"Fi`/E i4��=�� PHONE/ZU7, 9514 gT7� CONTRACTOR G'I�RK Lti/ LL //V G'. ADDRESS J/ L-"/7' 1�'e UC*-77/.S7n✓ PHONE/ 05' >>F7CA_-rzpA" 7 BUS CONTRACTOR ADDRESS UC/ RHONE 0- TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WILL/ ❑ OTHER ❑ m6TALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL B J N.11 Rep.1, H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL O RYPE OF RIMPI y ❑ OUT-OF SERVICE WELL ❑ OEOPIY6ICAL WELL/ 11 BOIL BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A - ❑ INDUSTRIAL ❑OPEN BOTTOM DtA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTIC"IVATE ❑GRAVEL PACK/GRE TYPE OF CASINGRITEEUPVC DIA.OF WELL CASINO D ❑ RIBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R J,R-{-T1yIRRIGATION/AG 11OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E lJ MONITORING GROUT SEAL PUMPED: ❑Ya ❑N. CONCRETE PEDESTAL BY DRILLER❑Y. ❑N. 5 APPROXI BE"" LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTION/dtlLUNO MUMD: MUD ROTARY_ AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT I NAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THE PERMIT IS 188UEO.I BIHALL NOT EMPLOY PER 6l OJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA: CONTRACTOR'S MMNG OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFOIIMAI LITE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 34 NOUIe i ADVANCE On ALL REQUIRED INSPECTIONS AT 12Oy ASSJAES. COMPLETE DRAWING AT LOWER AREA 1'ROIO 611n X Tee � i '�- D.le PLOT N ID'—W Bo.lel SC.I. 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROroSED Z. OUTLINE OF TILE PROPERTY,GIMNO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIM FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY On ADJOINING PROPERTY. - Ciy%Y'/.eo•y, Yen.', .-4 s7 OiT //1^''C .E7�✓�A I 6C� . PA� T!'ENT USE ONLY D.Ie Mu APp1ip.tl n A Oted BY O.te G.em In.PeonK.By D.te Pump Irnpectlen By De.tn.:nen Imneelbn By Cemment•: !�"'� ACCOUNTING ONLY: AID/ FACT PE CODES EE IN`0 AMOUNT RDNI TED CHECK CASII RECEIVED BY DATE PFTMITMERICE MOUE NVMNet INVOICE 3637 15 i i acT :z y 3S32 3 Pub.Health Sew.-Enviro.173(1/97)