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APPLICA?ION EORVELLIPUMP PERMIT %�eeiiir SAN JOAURN COUAITY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 96241388 p� (209) 468-3420 AEON-REFUNDABLE PERMIT EXPIRES 1 YEAR FRDAI DATE ISSUED 4 I� IC9mplate In Triplkate) APPLICATION IB HERE BY MADE TO THE SAN JOAGWN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN JOAQUfN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESSfDR APN/ I _ A,]l F,)... f_ '1 CITY PARCEL SIZEIAPNO OWNER'S HAMEGO,>1 t<t 2aA&. 0gMLk ., .,... ADDRESS PHONE R CONTRACTOR ./ ! ' —. G -/Wlal;.,5 l�SS71"J10bFtESS� �/'� T�1lA� ,lJC/ �7 PHONE (R I� SUB CONTRACTOR � I�►I1.�J�CR ADOhE68 �i r LICKS --.r��p� PHONE�S TYPE OF WELL/PITMP. ❑ NEW WELL ❑ FtEPLACEMENT WELL MONITORING WELL I '�� ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR © CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ ❑New❑Repair H.P. DEPTH PUMP SET FT. F (TYPE OF PUMPi IRBT WATER LEVEL O ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL 1 ❑ SOIL aumNO g DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTEOH SPECIFICATIONS A ❑ INDUSTRIAL 453 GRAVEL BOTTOM DIA.OF WELL EXCAVATION r� OfA,OF CONDUCTOR CASINO p 11DOMESTICIPRIVATE �r GRAVEL PACKISIZE TYPE OF CASINO/STEEGPVC ,2 y*r �kf'(,e DIA.OF WELL CASINO p ❑ PUBLICg41UNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R GATIONIAG 11 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E 0 MONITORING GROUT SEAL PUMPED: Yee ❑NO [IN. 5 r CONCRETE PEDESTAL BY DIVLLER:❑Yw APPROX,DEPTH_ LOCKING CHESTER BOXISTOVE PIPE S PROPOSED CONSTRUCTIONMAR.UN0 METHOD: MUD ROTARY AIR ROTARY AUGER—CABLE OTHER 1 HMSY CERTIFY THAT t HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE NAT"SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. "DME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE NT ST CA .Z4 HOURS IN ADVANCE FOR ALL REQt11RED INSPECTIONS AT 12091400-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Stoned% Title Date_ �'y�� 7 PLOT PLAN fbraw so Scale/@ease 'to I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIMCTiGM EXPANSION OF SEWAGE DISPOSAL SY9TFM9, 3, MMNMNEb OUTLMIF9 AND LOCATION OF ALL EXISTING AND PRIOPO9EG 6. LOCATION OF WFLLS WITHIN RADIUS OF ONE HUNDRED FiFrV FT. STRUCTUMN,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK$. ON THE PfOPERTY OR ADJOINING PROPERTY, 777 DEPARTMENT USE ONLY AppRcHlon Accepted By Oreul I—peotlen BY Dale Area � Dats Deetnrellen Impxltan By ^Pump Impaction By Data �--��. Date ACCOUNTING ONLY,- AIDI FACO PE COD" FEE INFO AMOUNT REMITTED CHECKIlCAaH RECEIVED BY BATE Z =0PERMITISIERVICE REQUEST NUMBER INVOICE S Pub.Health Serv.-Enviro.173(3196)