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APPLICATION FOR WELUPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES / ENVIRONMENTAL HEALTH DIVISION %1 033 304 EAST WEBER AVENUE, STOCKTON, CA 95202 V (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In TrlpOestal APPLICATION 19 I/ERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. Title APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-11155.3 AND THE _STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALIH Of ON. / JOB AODRE98/OR APN# I 'tel Ir l.:`; 1 -Si \ C'� I�LiFaL�� j ` CITYG ,J \40 �� ` r �+r��(/,�1 'n1 PARCEL SIZEIAF'NE _01 1"\ OWNER'S NAME S�-r;;c� T\f.�1 C�'�•1 A\�-L ii` �l Kl �,l �'l .�j'1'VLr ADOREgB I �++ Z- 1 ) e I j1 1 ✓LC` 1 KJ L'\ ALONE R CONTRACTOR E T 1 L A -s S C::t-'cA-' 11h1 ADORERS I l � U: \I— �J OA 06 LIC/ ALONE #L- jj r 2 2 SUBCONTRACTOR V WI i�J 1'l IIt+tt, ADDRES8 1 JCX..J1 r Z.Z; �L�� UCD V�' ALONE I �� ) •2J:I1 S. TYPE OF WELUPVMP: IR'NEW WELL ❑ REPLACEMENT WELL 'VIMONRORING WELL # - - 1 ❑ OTHER FAC! ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # IINF (REu(MO) ❑ New ❑ Repolr H.P. DEPTH PUMP SET FT- FIRST WATER LEVEL 0 (TYPE OF PUMPI RE96,V BY - -- TISEAVICE REQUEST NUMB INVOICE ❑ OUT -0F -SERVICE WELL ❑ OEOPt1YSICAL WELL # ❑ SOIL BORING g ❑ DESTRUCTION: NII INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION o 1 J,(�L, DIA. OF CONDUCTOR CASINO ; Vi T 0 ❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASINO/ST EEt/PVC V L= DIA. OF WELL CASINO Z I 0 ❑ PUBLIC/MUNIC IPAL ❑ DRIVEN DEPTH Of GROUT SEAL f I- SPECIFICATION . i 0 g ❑ IRRIGATION/AG OTHER GROUT SEAL INSTALLED BY 7'y LiY11y- a, ��L- ``,, --• GROUT BRAND NAME O-L'AI ZA, �WMOMTOMNOGROUT _ z h � �yVae SEAL PUMPED: 19 ❑ No CONCRETE PEDESTAL BY DRILLER' ❑Yee e S APPNOX. DH EPT J -S e e LOCKING CHESTER BOX/STOVE APE S PROPOSED CONSTRUCTIONIDRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER_ CABLE OTHER I HEREBY CERTIFY THAT I )LAVE PREPARED THIS APPLICATION AND THAT THE WOR( 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` T1419 PERMIT IB ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: ' 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WONKMAN'S COMPI NSATION LAWS Of CALIFORNIA.' THE APPLICANT MUST URS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120!1 I00J422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X Tlt10 .".A / Det• ....(( Gs PLOT PLAN rDl 1. Boole$ Scale ' to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. /. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED � 2. OUILnIE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF 8EWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WrTHIN RADIUS OF ONE HUNDRED FIFTY STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS; DRIVEWAYS, AND WALYS. ON THE PROPERTY OR ADJOINRM3 PROPERTY. h KEU OR T.I. Sa" 1 AID# FAC! 111 ENI IINF (REu(MO) I ' IT AMOUNT REMITTED CHECK#/CASH RE96,V BY - DATE TISEAVICE REQUEST NUMB INVOICE DISPENSER (RENO M , NII I so -i I sa Z BUILD114C uw-i(PA(%'OSED) /I —PRODUCT SUPPLY PIPING (RFNObTD) / 00 wAS1E paPO5A1 W11- APPRO%. IINR Of C%CAVI.DD11 .... ... ///zz SBA -t CONCRETE PAD `r I F(7 0 I 117 PROPOSED MONITORING WELL LOCATION q) SOIL BORING LOCATIONS�n i 1 / DEPARTMENT USE ONLY APplleetbn AeoepleA Omar Inspection By DnetnEetlen Inepeetlon Comment.:) r-ce ,r' i ,,n s l Dote L/ / Q I/ // Pump Inspeetlen By ■Ii II[IMICN-+I INNIA STOCKTON UNIFIED SCHOOL DISTRICT CROUNDViATFR INVFSTIGATION PROPOSED LOCATION OF MW -1 S TAGG HIGH I I SD IDOL I �J73 � (IUHIi � 9 Dale 2— ` / i VV `1( i\u T � t o r M Dote ACCOUNTING ONLY: AID# FAC! PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RE96,V BY - DATE TISEAVICE REQUEST NUMB INVOICE Pub Health Serv. - Enviro. 173 (1/97)