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mom r M m o m M M Ff x'11 �1 ir�'rirlfl'etiM x�+'e'1s°gni erl • ��'a'I{� t. il��..t',��r��'7�f�{y r1�rTl'��i,�Fk7'•a rPiel-+--T-�tr -w9 - r r r 1 r' APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION RE CR I V E D P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON. CA 95201308 1209] 408 3420 MAR 2 8 6% i _ R FROM DATE ISSUED RUM REFUNDApIE PERMIT EXPIRES t YEAR .....�,,.. t ~ (Complata In Trl Heata) ' At'PI ICATIUN 18 HERE BY MADE TO 111E SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED THIS AMicAT10N IS MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVEI OPMENf MSE CHAPTER 9 1111533 AND THE STANDARD@ OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENfAt IIEALTH DIVISION • 1 I el JOB ADDREBSIOR APNA . CITY PARCEL SIZEIAPN#Al 9e gtA-4-- -5-"111I i I OWNERS NAME 1 . ADDRESS f� 1{ONE# O CONTRACTOR ! ADOREBB'QO LICf4S AGPHORr# BUS CONTRACTOR , ADDRESS LIC/ PHONE# 1 TYPE OF WELLIPUMP ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL.If ❑ OTHER 1 ❑ INSTAL ATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑Now❑Repair FI P 1 DEPFH PUMP SET FT F!R WATER LEVEL p {TYPE OF PUMP) ❑ OUT OF SERVICE WELL 13 GMPHVS" Il 0 A.- 8 )HJEBTRUCTION toGtA,�' Merl . INF[-DED i8 IYPE OF WELLCONSTRUCTION O ON A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA OF WELL EXCAVATION DIA OF CONDUCTOR CASINO p ❑ OOME91ICR'RIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELIPVC DIA OF WELL CASING D i r ❑ PUBUCfMUNICIPAL ❑DRIVEN DEPT"OF GROUT REAL SPECIFICATION A ❑ tRR10AT10NIAd ❑OTHER r I ; ' GROUT BEAL INSTALLED BY GROUT BRAND NAME E I ry ❑ MONITORING t GROUT SEAL PUMPED ❑Yee ❑No CONCRETE PEDESTAL BY DRILLER [IV. ❑No 8 APPROX DEPTH LOCKING CHESTER 80XIBTOVE PIPE 8 PROPOSED CONSTRUCTIONM#VLUNG METHOD MUD ROTARY AIR ROTARY AUGER CABLE OTHER S R 1 IIERE t-gjRTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH CAN JOAOUIN COUNTY ORDINANCES STATE LAWS AND RULES AND RFGULATIONh1gF 711E BAN JOAOUtN COUNTY HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS{ERM/[IB Ik�LrED I SHALL NOT EMM OY PERSONS SUBJECT TO WORKMAN E COMPENSATION I AW@ OF CAI IFORNIA• CONTRACTOR 0 NIRINO OR BUB CONT RAC IIND SIGNATURE CERTIFIES THE FettOWN0 I I LER11FY THAT IN-1 PIE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN a COMPENSATION LAWS OF I ` CALIrORNIW-TdE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1200)48S842* COMPLETE DRAWING AT LOWER AREA PROVIDED I ? 91prred X Title ' r Dns_ 1 PLOT KAN 91raw to Boole)Bo.1e_ f „.to 401 1 ' I NAMES OF STREETS OR ROADS NRAW91 t0 OR NOUNOtHe THE PROPERTY, 4, LOCATION OF HOUSE AEWAOX DkNM* I SYSTEM 13111 L A"StO I 2 OUTLINE OF TIRE PROPEIITY,GIVING DIMENSIONS AND NORTH DIRECTION EXPANSION OP SEWAGE DISPOSAL SYSTEMS. 1 3 DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED S LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, 61 RUCTURES INCLUDING COVERED AREAS SUCH AC PATIOS,DRIVEWAYS,AND WALKS DN THE PROPERTY OR ADJOINING PROPERTY r r r p t � r r r ¢ l } if } I 1 r o � � ,�ytrM.tirslrM =t �■ I t = FFF s I = , I � i 4fl7r,?d . b + l� DEPMTMENT USE ONLY Apptleation Accepted By My Om. r � a Grout Inspeatlon By Deo. Reny hnpsellen By OEM DooUuellon Irnpeatian By Dale rl Comments W p tT Tt41✓ ; lw (r ACCOUNTING ONLY AID# FAC! 3 5.oz, PE CODES FEE INFO AMOUNT REMITTED HE ICASH RECEIVED BY DATE PE RMITISERVICE REQUEST NUMBER ]"VOICE R I lY 4 4