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APPLICATION ' .! WE' LIPUMP PERMIT ..AN JOAOUIN COUNT? PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION I P.O. BOX 388, 904 EAST WEBER AVENUE, STOCKTON, CA 95201388 (2091 466.3420 MON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED IComplets in TripIle111111 APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORT( DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-111115,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLICHEALTHSERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDMssmR APJI �4Y/Y //7(/Izoc //r///=SL A. CCITY F � • , AODIIEBB(/] y��y(�J� PARCEL SIZEAPN* OWNER'S NAME 1lAlrPHONE / q z�tyr TTJJ PHONE # I? /fes �) /- .STOL.CTLN fiJ y�yp7 ONE • 'd �p CONTRACTOR /]'/.(//Fy/�L� L7G� C///%lI�'I/f �y ADDRESS /' rlc � G�-�y¢UCI SUB CONTRACTOR ADDRESS �04 'I ✓e meMFyr �, / I PHONE I TYPE OF WEU/PUMP: LJ NEW WELL ❑ REPLACEMENT WELL L?MONITORINO WELL I OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑ Have ❑ Reear H.P. DEPTH RUMP SET_FT, FIRST WATER LEVEL O (TYPE OF PUMP ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL A ❑ SOIL ROBING g ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ( ( � / A A 11 INDUSTRIAL ❑ OPEN BOTTOM DIA. OFWELLEXCAVATION /A,90 • Q7•' /. IO DIA. OF CONDUCTOR CASINO NAt D El DOMEIPRI STICVATE � O ' RAVFL PACK/SIZE TYPE OF CASINGISTEEUPVC y - DIA. OFWELLCASINO y D ❑ PURUCIMUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL J� ",. � SPECIFICATION .u/� R IO ❑ IRRIGATN/AG ❑ OTHER GROUT SEAL INSTALLED B`!L'.Z?LYjTV GROUT BRAND NAME /r/li/T� Ii E MONITORING GROUT SEAL PUMPED: Ely" 0 N CONCRETE PEDESTAL BY DRILLER: ❑ Ym ONO 5 APPROX. DEPTH LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONSTRUCIION/mBLUND METHOD: MUD ROTARY AIR ROTARY AUGER_ CABLE OTHER - I 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING! '1 CERTIFY THAT IN THE PEPIORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED, I SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: • 1 CERTIFY THAT IN TINE PERFORMANCE OF THE WOR( FOR WHICH THIS PERMIT IB ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'11 COMPENSATION LAWS OF CALIFORNIA.' T/ CA! LL 24 M Y IN ADVANCE FOR ALL REQUIRED INNSSSPECTION$ AT 120111 A011JP 423. COMPLETE DRAWING AT LOWER AREA PROVIDED. 4 e111m0 x ( � Title f'A //Zr � EOE?�7`" Gets /IC �4' PLOT PLAN IUrxto Bowel Bene • to 1 . NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM GR POPOsED 2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE GRIMM SYSTEMS, 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, DEPARTMENT USE ONLY 9 APWbelbn Aevepled ByN Dae At Grout ImPaotlon By Dae Pump ImomOen BY Dae Deatncllan ImPealo By I Da Cemmm GTi�o ACCOUNTING ONLY: AIDS FACE ' PE CODES FEE INFO AMOUNT REMITTED CNECKI/CASH RECEIVED B DATE PERMITISEAVICE REQUEST NUMBER INVOICE Pub. Health Sew. - Enviro. 173 (3/96) Copy K