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APPLICATION FOR WELLIPUMP PERK" SAOAQUIN COUNTY PUBLIC HEALTH SEICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NOR-REFUNDABLE PERMIT EXPIRES ! YEAR FROM DATE ISSUED (camcatal APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT 1 RUCTANDIOn INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE VMH SAN JOAQUIN COUNTY DEVELOPMENT TTTLF,CHAPTER B-1115.3 AND THE STANDARDS Of SAN JOAQUIN COUNTY PUBLIC HFALTtT SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDFSSIOR APNI� 7p [)�Ty f f)( 179 CITY L a n ,,,` � I PARCEL BlZEIAPN/ OWNEA'S NAME �7xi; 'kwC2 „ADDRFSB rr396 h+'GjIti/* (Ict (/ fyl; PHONE'z; c f" CONTRACTOR t31r-0iI/y #'4N40 CfVi,owe-j-L jl I - - 4 ' r f� ADDRESS LIC,! PHONE i1 /L Y7y'L�23 Bub CONTRACTOp Ii1 EaDDIA� b p1211j-1n/CT t^i ADDRESORA 97Q)C:7S'16 re'jtl vj5i 7-/ C„ WC-7-37 7 71/ 360 TYP£OF LALLIPUMPt ❑ NEW WELL ❑ REPLACEMENT WELLW MONITORING WELL,F+h ❑ OTHER ❑ INSTALLATION ® WELL SYSTEM REPAIR �❑" CROSS-CONNECT REPAIR © VAPOR EXTRACTION WELL 13 1 New❑Repsl. H.P. DEPTH PUMP BET FT. FIRST WATER LEVEL ii-F OF Ft/MPl O ❑ OUT-OF-SFRVICE WFtL ❑ GEOPHYSICAL WELL X ❑ SOIL BORING R ❑OESTRVCTION INTENDED USF TYPE Of WELL CONSTRUCTION SPECIFICATIONS INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION__. DIA.OF CONOUC TOR CASINO �� A CI 11 D DOMESYICIPPIWATE ❑GRAVEL PACKISIZE TYPE OF CASMOISTEEUPVC Pyc DIA.OF WELL CASINO j� + _ n ❑ PUSUCIMUNIMPAL ©DRIVEN DEPTH OF GROUT SFAL SPECIFICATION R ❑fIRRMATIONIAG D OTHER GROUT SEAL INSTALLF)BY GROUT BRAND NAME F X,♦G! MONITORING OROUT SEAL PUMPED: ❑Yap ❑Ne CONCRETE PEDESTAL BY DROLLER:❑Vs ❑Ne S APPROX.OFPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTROCTIOWMI-LING METHOD: MUD ROTARY AIR ROTARY AUGEA___2(_CABLE OIHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWR.ANO RULES AND REGULATIONS Of THE SAN-IOAOUfN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIPIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR YVPICH THIS PFRMIT t8ISSUED,181TAI.L NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTINO SIGNATURE CERTIFIFB THE FOTI.OWINO: I'CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Of CALIFORNIA.'IT APPLICANT MUST C/A 4 HOUR�S/IINA�DVANCF FOR ALI REOLSAW 1 PECTMNG AT 1"01 4B1342K. COMPLETE DRAWING AT I OWER AREA PROM , p.>� I Thlo �' --".�..�� D.. 7K PLO)PLAN IDrew to Bo.lel Sade 1. NAMES OF STRFETS OR ROADS NEAREST TO OR BOUNntNO THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED S. OUTLINE OF THE P'RUP'ERTY,OWING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OVTLINFS AND LOCATION Of ALL EXISTING AND PROPOSED S. LOCATION OF WELLS NRTHIN RADIUS OF ONE HUNORED FIFTV FT. STRUCTURES,tNCLUDtHG COVERED AREAS SUCH AS PATIOS,DFVVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PYROP IEnty. j I SE M1'(''-1 4P `Pzc r-lasS tb W-E LL LC,0-''io V A" IVO. y 0 FFtc45 T1rc- Mw- a s w • Fv z ryto R-c D,- i� DEPARTMENT USE ONLY Aopll,:et+on Acc m Rr Dote_. O� L] A," 0-0 Ir»PecNon BY Dote P�p InopeatTen BY Dete Ow.tat�eelen t—p—tion Py Dole f.a--ft't•: ACCOUNTING ONLY: AtDR FAC/ PE CODES TEE INFO AMOUNT RfMTTED CHECK/ICAAH RECEIVED BY DATE PE MfTISETVICE BEQUEST NUMBER INVOICE r ialth Serv.-Envirb.173(1/97)