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�-" APPLICATION FOR WEWPUMP PERMIT � A JOAGUIN COMITY PUBIIC-HEALTH SERVIC { ENVIRONL'ifit�ALLNEALTII DIVISION ,_ ,:Ir P.O. Box SK 304 EAST WEBER AVENUE. STOck�6 -bk-- .� A 1_rf i (209) 469-3420 '>>~ NON-REFUNDABLE PEIR�M PEmulets In s IrYE R FROM DA*4S — PH��: 53''" APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CFIAPTER 8-111 S.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH.SERVICFS,ENVIRONMENTAL HEALTH DIVISION. ' �/} n tTa LLCTonI iT R,�.E T , JOB ADDf*'$ OR APNI -7 3 ! S'ITV I F'r W A -0 - Y CRI'STO G lC�p Ai � - -^�PARCEL 8=APN! ' Sw tf-TL TP-HAjs ajzna cA) �' D vwNETG•t1 NAME P � . rLDDREss .�L� I la:Ed T' r �� PHONE 16 Z—3S Z- O n n r CONTRACTOR W ES T,Etc _.... __ 'ADDRESS .1900 00 SOUTH R iy iC k 9 y.LIC. 5--C2199 PHONE* -?73)/)f� w- s� - .SUB CONTRACTOR - -- ADDRESS L,ICI PHONE I 1 TYPE OF WEU/RJMP; XNEW WELL ❑ REPLACEMENT WELL - ICI.MONITORING WELLS.. m, ❑ OTHER . ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CFOSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WEU,I J [3 New❑R.Palr - H.P. DEPTH PUMP BET FF. FIRST WATER LEVEL 3 I - o FTYP;OF PUMP) 13OUT•Of SERVICE WELL ❑ GEOPHYSICAL WELL I n ❑ SOIL SOFSNO B i..I DESTRtICT10N: LNTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS .k4 ❑ INDUSTRIAL ❑OPEN BOTTOM OLA.OF WELL EXCAVATION L o I N L 4 DIA.OF CONDUCTOR CASINO ❑ DOMESTICIPRIVATE ®GRAVEL PAMISMY 2 t'L Z TYPE OF CASINOISTEEUPVC T'Q G S L'l 0 - DIA.OF WELL.CASING D ❑ PUBLICSMUNK:IPAL ❑DRIVEN _ DEPTH OF GROUT SEAL 2 F T SPECIFICATION .O-2 Sc A F:r=Aj R �❑ wouoAT owm ❑OTHER GROUT SEAL SEINSTALLED BY %W �E X GROUT BRAND NAME_PcX-T 4 4-i b c�MENT :E LCL MONTMF13NG GROUT AL PUMPED: WLY. 13N. - CONCRETE PEDESTAL BY DRILLER:M Yr ❑No S 3 APPRtOX.DEPTH S O F-t LOCKING CHESTER BOXMTOVE RPE S 4` PROPOSED CONSTR UCTIONIDRILLINO METHOD: MUD ROTARY AM ROTARY -- AUGER__,>< CABLE OTHER I Hfc"Y CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORC 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 MHATURE CERT►F.ES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORIURAN-S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR RUB-CONTRACTING SIGNATURE CERTFREI THE FOLLOWWNO: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMFF IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF C:AUFORNIA.• TILE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED MWWTFONS AT")4p4422, COMPLETE DRAWING AT LOWER AREA PROVIDED. Sion.dx .-. i7►+.[�+�.� TIW -RaE-c_r_ - &J04-acrtyl— _ Dt.�G" �4 PLOT PLAN LDrew to SoehIy1 S.d. to A,-MA<-" 1. 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 DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. , 3. DI.tENRONID 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. .............i......r - .....:.............. -.i - ..........:......: ....—-...... ....:.. .. ..:......:............. ......'... -. .. - .. .. .. .. ......... ......... -- -.:.-....:.. -.- .ti-.- ....... ...........:......J......i... .......i..._..-...-.. .... .. .. .. ...,.».? .. .. i I .....................:.....:.......................:.......: .. .. .. .. .. .. .. .. ......... .. .. .. .. .. .. ............. .. .. .. .. .. .. ... .. ...............:. ...:............. .. .. .. .. - ......... .. .. .. .. .. .. .. .. .. .. .. .. �. - _ I DEPARTMENT USE ONLY APPIio.lbn AooWled By .. Late �VL / ` Arr�.1��..�.� Grwl Imps"Ien By Date Pump Irmpectten by: ri- Date r Dmmjctl m bepeogen By Date ' emn+ont.: - a fx-C. ACcotRITTNO oNLY: AMP FACT !i PE CODES FEE INFO AMOUNT RElVaT n CMMKIfCASH RSCevED BY DATE POW Tis n-CE REGUEaT N 1 ICE