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APPLICATION FOR WELUPUMP PERM'' SA►�Vw4AQUIN COUNTY PUBLIC HEALTH SE*,,Illlii10ES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON•REFUADABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complote fn TripUestil APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORIK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THESTANDARDSOF RAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DPAStON. 7 p JOB ADDRESSIOR ArrPNff . 5 2 3 LFS) `I ,{ f=IV �y"�� 7 I�tA_F..r T ..CITY ( fi A L Y PARCEL SIZEIAPNR 236_1 7 !3 OWNER'S NAME.,% 4�L!'t1 1 O S l�N .� f�IN yL U•C ti`i ADDRESS itZ�L�Z W '� Ave L r� �! ,,p 1`' ♦ (�� —zi tar r,to k'1 d G ,9 FJ"i.. '� :y/�p PHONE A`z o l•4 6 z'2 C)1 0 CONTRACTOR Y r # IY YT - ADDRESS � a V 1. �� ,� I UC/7 LY 1 pHONE P 0 ' 1- SUB CONTRACTOR ADDRESS tics PHONE s TYPE OF WELUPUMP: KNEW WELL ❑ REPLACEMENT WELL MONITORING WELL f. mw—1 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL s J 11New❑Repe4 H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O I fl VPE OF PUMPI ❑ OUt-OF-BERVICE WELL ❑ GEOPHYSICAL WELL Of © SOIL BORING 8 1 ❑DESTRUCTION: - INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS "'i p A 11 INDUSTRIAL Ej OPEN BOTTOM DIA.OF WELL EXCAVATION Fi" i' DIA.OF CONDUCTOR CASINO--- 14A O 11DOMESTT'B ICIIVATE L�GRAVEL PACKISIZE S�i n cl TYPE OF CASINGISTEEUPVC_ _ r GIA.OF WELL CASINO Z/1� �Y11��, O 13PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL f ` BPECtFICATION SZ I la � 0:0 Z0 S ICt F 11IRRIGATIONIAG 11 OTHER GROUT SEAL INSTALLED BY tZ hA I f M GROUT BRAND NAME eo t-t ee Wi 1? E IrMONITOAINO GROUT SEAL PUMPED: ❑Yee Ne CONCRETE PEDESTAL BY DRILLER:O YNo y 5 APPRGX.DEPTH .0 Feet LOCKING CHESTER BOX/STOVE PIPE ��S I1 5 �� 7i CX S PROPOSED CONITRUCTIONIDPoLLING METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER i I HEREBY CERTIFY TIIAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY 0ROMANCES.STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH I THIS PERMIT IS ISSUED,t 614ALL NOTEMPLOY RBONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT iN THE T-I.R.ANCI RFORMANCE OF THE WORK.FOR WHICH THIS PERMIT 16 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOMWAN'i COMPENSATION LAWS OF f CALIFORNIA.' E APPLICANT UST CA 21 HOURS IN ADVANCE FOR ALL REGUIRIb NiPtCitO BAT I20/!4ef342], COMPLETE DRAWING AT LOWER AREA PROVIDED, Slonwd X Tltl ! DNe /CJ-Co^7 J Y 1-11 PLOT PLAN IDrRw to Boelel Gaels 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. R, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSEU 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 7, DIMENSIONED OUTLINER AND LOCATION OF ALL EXISTING AND PROPO BED 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. . .... .....,. ...r r.. r.. _ .., - ... .. . A. � Jili, p..'..h°L/ J ...... Y a DEPARTMENT USE ONLY . AoPllcetlen Aeeeptml By q Dots' Z Arae Ar O.eln Impeetlnn SY Oate Z-\ Rwnp Inepeetlen BY Date Dwelnrctlen tmpecllen BY Date - I Cmmmenu• ACCOUNTING ONLY; AID/ FAC! PE CODES FEE INFO AMOUNT REMITTED CHECKSICAIH RECEIVED BY :.DATE: PEIIMITISERVICE AEGUEitNtsNBEEi INVOICE Pub.Health Serv.-Enviro.173(1197)