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e140 - APPLICA""A FOR'WELLIPUMP PERMIT SAN JOA(IA CIOUWY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX SW 304 EAST WESER AVENUE,STOCKMN, CA 95201-388 (2091469-3420 5/ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED Ca 3 `lf� ICompl&t&IR TApBeats) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER B-1 116.3 AND THE STANOAROS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APNX CIT-Ir PARCEL SIZEIAPHO OWNER'S NAME rr ADDRESS PHONE N CONTRACTOR f�/[iY'r+164 llL cl7.S4�Lr.i!Q 1 r3�5.__---_- -—ADDRESS 3QS 1 LICK PHONE t WeS: $A , CA �T SUB CONTRACTOR ADDRESS LJCt a T:;(06 ST'HONE i ,S TYPE OF WELLlPUMP: ❑ NEW WELL © REPLACEMENT WELL MONITORING WELL IOTHER © INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL! J ❑New❑Rep Nr H.P. DEPTH PUMP SET Ft. FIRST WATER LEVEL O IT YPE OF PUMPf ❑ OUT--O/F-sEERVIyyC..E..WELL -rn_p ❑ GEOPHYSICAL WELL I _ A ❑ colt BORING P�ERUCTION: liQ� 6ngwA�+ _ zk1h;C Mer- /LII 44Z /1, 9:x� 'T{] SWI�IQ CE- INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO_ D ❑ OOMESTICIPRIVATE j.—VEL PACK/SIZE TYPE OF CASINGISTEEUPVC_ q/I - r I[� DIA.OF WELL CASINO D ❑ PURLICIMUNICIPAL ©DRIVEN DEPTH OF GROUT SEAL: ,._,., SPECIFICATION .V2!C) _XceP X.9 4-0 R ❑ IRRIGATONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ONFTORONG GROUT SEAL PUMPED: ❑Y. ❑No CONCRETE PEDESTAL BY DRILLER:❑Y. [IN. S APPROX.DEPTH 4t_ ^� LOCKING CHESTER BOXMTOVE PIPE S PROPOSED CONSTRUCTIONMAILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HE-03Y CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ANO 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TFIS PERMIT HS ISSUED.I SWILL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CEntWY HAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' TN9 AT PUCAN UBT C 24"OURS IN ADVANCE FOR ALL REQUIRED INSPECTION&AT 120011408-2423. COMPLETE DRAWING AT LOWER AREA PROVIDED. SlOned X Title.. PLOT PLAN{Drew to Soolel Stele 'to 1. NAME OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2, OUTLINE OF THE PROPERTY.OWING DMAENBIONS AND NORTH bIRECTX]H. EXPANSION OF SEVYAOE DIBPOBAL SYSTEMS. 3. DIMENSIONED OUTtW.4 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WEl lei WITHIN MORN OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDHMO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. sees : . I . ............ .I........... DEPARTMENT USE ONLY Applicatlan Accepted By C C Det• OF, /7 r Arse Grain I_Poot$n By dere P�p Inspection By Deslructlen impeellon By Date Deta Comm&,ty ACCOUNTING ONLY: AID/ FACb PE CODES FEE INFO AMOUNT REMITTED CHECK/!CASH RE O By DAT ER PMITlSERVICE REQUEST NUMB91 INVOICE s8 s 2-- Pub. Pub.Health Serv.-Enviro.173(3196)