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APPLICATION FOR WELUPUMP PERMIT SAN JOAaUIN RVI ENVIRONMENTAL HEALTH DIVISION 1StZO Z.. 304 EAST WEBER AVENUE, STOCKTOfI, CAS (209) 4883420 �(� NOW-REFUNDABLE PERMIT p M APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TM.L,�CHHAPT�EER�.$�-11155,.33 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIV�If810N. /C JOB ADDRESS/OR APN{I'-'� �(J7 ry�j�(�l✓1,.M1}{J 11'�. 1}�(J CRR' - i'l •. - PARCEL SIZE/APNf �'{/j/�,ll i In/.�(jl �,(/-) OWNER'S NAME sl I ICkJ(L�l/�ll�fl 7 1/ I ADDRESS I 1 I PHONE I_QgJ-1- 89-✓ rd CONTRACTOR (iM I Y, ')+ k�/►W��f� ADDRESB 0 PHONE SUBCONTRACTOR U�I Y c�.Vu,.l I ADDRESS IJCS PHONE 0 TYPE OF WELUPUMP: ❑ NEIN WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ❑ New❑Rttpelr H.P. DEPTH PUMP BET FT. FIRST WATER LEVEL O (TYPE OF PUMPS ❑ OUT-o"ovVICE WELL ❑ GEOPHYSICAL WELL I SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMETM/MVATE ❑GRAVEL PA=JSQE TYPE OF CASING/STEELRVC DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN ,, DEPTH OF GROUT SEAL r)' r SPECIFICATIONR ❑ IRRIGATION/AG §oOTHER9)IL Ncl- GROUT SEAL INSTALLED BY L�" GROUT BRAND NAME E X MONITORING/,�tV IKC GROUT SEAL PUMPED: ❑Y. G N. CONCRETE PEDESTAL BY DRILLER❑Y. ❑Ne S APPROX.DETTHS LOCKING CHESTER BOXISTOVE PIPE S PROPOSED CONSTRUCTION/DIG METHOD: MUD ROTARY AIR ROTARY AUGER V CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE 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. 140ME OWNER OR LENSED AGER.'^a=NATURE CERTIFlES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORMA.' CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFlES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TMS PERMrT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA_' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL 11EOURED-IRISS�P•'FI�O,�NSp AT/,r"*$4"-342l. COMPLETE D AWINGQAT/LOWER AREA PROVIDED. Blond X T.� Ir FC_f V 4'/:./161A) �< �(. 7 f/`-li��K�t`D.t. y ' PLOT PLAN(Draw to Seele)S.ele to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUNE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOIMNO PROPERTY, .� . -- .. ._ --- — ---- — _ - - ............ ......{::.... ........ MAP ON BACK ............ ...... ...... ............. ...... ....................... ...... ........................... .. . ......... ..................... ........................................................ .......... ............ ..............a.................... ........ DEPARTMENT USE ONLY ( C� Applloetlpn Aeeepted by Dela S Z" ( Grout Impeetlon By Dat. [ Pump Irspeetlon By Det. Deer u tlon Irt.peotlon By OSta ACCOLINTING ONLY: AIW FACT PE CODES FEE INFO AMOUNT REMITTED C ASH RECEIVED BY DATE PIRMITISOWICE REQUEST NUMBER INVOICE bb �S (�