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I 1PPLICATION i=OR WELUPUMP PERM17 ' SAI�rr„II►AOUIN COUNTY PUBLIC HEALTH SE1 ;ES �---ENVIRONMENTAL HEALTH DIVISION ' 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complet.In TTIpRt aul APPLICATION IS HERE By MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.TMe APPLICATION IS MADE IN COMPLIANCE WHIT SAH JOAQUIN COUNTY DEVELOPMENT TITLE. V TLLE.CHAPTER 9-1111 IS 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. - JOB ADDREBSIOR APNI V , �1'�� (�• CITY OWNER'S NAME D'D'�e Q�� fil� ,/PARCEL BIZEIAPNI y7�]]7 a ADDRESS !y (' Q11 PHONE OX-IS "L d CONTRACTOR c�W GLY 9f f I is, c ADDRESS I v[r7� ( ucr Y��' PHONE W SUN CONTRACTOR ADDRESS LIC/ PIONS/ TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER I ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR © VAPOR EXTRACTION WELL F J ❑New❑P.P.1, H.P. DEPTH PUMP SET FT• FIRST WATER LEVEL p ' IT YPE Of PUMPI old /1 pI11 _ / ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL R ❑ S01L BORING olCt D.. I[�Ct+ KYDESTRUCRom: VA`� Wdls WLI Mto 2 f)IW- (ti W- ryi k}- W- nj DM-1__ IN tF.NbEO USE..�� .. ---TYPE OF WELL - - �- - CONSTRUCTION SPECIFICATIONS- •4 r ❑ INDUSTRIAL ❑OPEN BOTTOM VIA,OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMESTICMMVATE ❑ORAVEL PACK/SIZE TYPE OF CASING/BTEELIPVC DIA.OF WELL CASINO D ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION q ❑ IRn1GATIONlAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E i ❑ MONITORING GROUT SEAL PUMPED: ❑Vee [IN. CONCRETE PEDESTAL BY DRILLER:❑Yer One S APPROX.DEPTH LOCKING CHESTER BOXISTO P g PROPOSED CONSTRUCTIONIDRILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER i I HERESY CERTIFY THAT T NAVE PREPARED TMS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS Of THE SAN JOAOLIRH COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOKS FOR WHICH TMS PERMIT 48 ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S MRINO OR 8118-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUNJECT TO WORKMAN'/COMP"IIATTON LAWS OF CALIFORM 'jTHTHEEAPPLICANT•�MUST CALL l 11 IN ADVANCE FOR ALL"KOMI* SPECTIONS T I2g0)4004422. COMPLETE DRAWING ALpT,LOWER AREA�P}ROWDED, [xy Signed X i 5 _ \ ~j .Tlt1e_�:J' nq'nvs ) I-m.A Rl��i'R 31 tif. O+ta V 3 I Q 6 f l PLOT PLAN Phew to Seels)same_'1 6 1. NAMES OF STREETS OR ROADS NEAREST TO OR BORINOINO THE PROPERTY. 4. LOCATION OF HOUSE BEWAOE DISPOSAL SYSTEM On PROPOSED 2, OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 1 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 11. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY F7. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ..,i,.., i. .., ,......... .. ..........:.. ..: ., ....,... .. ., ., ., i'. i , f J r .. .. .... .. ...... ...... ... ....... .. 0 • ;. - ................... .... .. eZ m>N .:................:......:.....:......:.... ... DEPARTMENT USE ONLY f Appllaetlon Aeaepled BY�� 0( 1- Doe 1. Al" Y / G+wA Impem0an av Data RXn�IMpeetlen be.tn�tbn InePeoelen By _ 1Lb 6c mde-rArt Dale.F rf Cernmente: rn 4- o dam>� c at rts5c�. o I ACCOUNTINO ONLY: AIDI FAC! - i PE CODE. FEE INFO AMOUNT REMITTED CHECKEMASH RECEIVED BY DATE PEI MITISEAVICE REQUEST NUMBER INVOICE 3 sod. d i s Pub.Health Serv.-EnViro.173(1197) MWS o n gepaul`c.�e farm*. ,