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APPLICATION FOR VVELLIPUMP PERM' SAN JOAQUIN COUNTY PUBLIC HEALTH Sb..,CES ENVIRONMENTAL HEALTH DIVISION P.O. SOX 388, 304 EAST WEBER468-3420 AVENUE, NE, STOCKTON. CA 95201388 109 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED AN (Complete in Tripliicatf) ARDS N SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. pPLtCATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMITTOCONSTRUCT AND10R INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH S OAOUIN COUNTY DEVELOP/M•-ENT TITLE, CHAPTER 9-111/5.3 AND THESTANDARDS <, Y � - PARCEL SIZE/APNI ---------- I �r i�l,44/ CITY I �j�q uZ OB ADDRESSIOR APN+1 ADDRES6 I ` LV �n� ��Gt SONE+f 17192--OV-4- 08 � O p nCNv l "�""� � 1/0� )WNER'8 NAME ADDRESS ► , �? ��n UCR!� PRONE ;ONTRACTOR I I PHONE 0 ADDRESS 3U8 CONTRACTOR hh MONITORING WELL 80 OTHER ❑ REPLACEMENT WELL VAPOR EXTRACTION WELL O TYPE OF WELL/PUMP: NEW WELL ❑ CROSS-CONNECT REPAIR FIRST WATER LEVEL ❑ INSTALLATION ❑ WELL SYSTEM REPAIR DEPTH PUMP SE-T-----Tr' ,�../ 6 ❑Now Repair H•P•sSOIL BORING �(f YPE 0� ❑ GEOPHYSICAL WELL+��— ❑ OUT-0F-SERVICE WELL A ❑DESTRUCTION: I D CONSTRUCTION ePECIFICATIONe l` + DIA.OF CONDUCTOR CASING INTENDED USE TYPES r D ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF WELL CASING ❑ INDUSTRIAL TYPE OF CASING/STEEL/PVC R ❑GRAVEL PACKISIZE�— 1 SPECIFICATION t( ❑ DOMESTIC/PRIVATE DEPTH OF GROUT SEAL Y"7' E ❑ PUSUCCJIA%�_MIUNICIPAL ❑DRIVEN GROUT BRAND n + GROUT SEAL INSTALLED BY CONCRETE PEDESTAL BY DRILLER:❑Yw ❑No 5 ❑OTHER ❑ IRRIGATION/AG GROUT SEAL PUMPED: ❑Yea ❑No 5 MONITORING LOCKING CHESTER SOXISTOVE PIPE__ OTHER— / 1 AUGER CABLE---� APPROX.DEPTH AIR ROTARY�� PROPOSED CONSTRUCTIONMAILLING METHOD: MUD ROTARY____�- -ORWH NTRACTOR'8 HIIUNG OR SUBLONTRACTIN6 SIGNATURE CERTIFIES S ANIJ CH D AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: CERTIFY THAT IN THE PERFORMANCE OF THE WOLAWS OF HAVE PREPARED THIS AppUCATION AND THA 8E HE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCE8,STATE U1W8,AND RULE THE CERTIFY THAT 1 HOME OWNER OR LICENSED REGULATIONS OF THE SAN JOAQUIN COUNTY' THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT HE FOR,FOR WHICH THIS INSPECTIONS ATOmpENSATION LAWS Ol20o)CALIFORNIA.- COMPLETE DRAWING AT LOWER AREA PROMO 0'� 1�� WINO: I CERTIFY THAT IN THE PERSONS SUBNCE J F THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO Dote COMPENSATION2 /J THE FOLLO LL 24 HOURe IN A r ,� CALIFORNIA.' T APPLICANT II a � (, r� Q�� Title Slpned X 'to-- PLOT PLAN(Draw to Sc*le)Sul* 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOS ED PERTY- EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 1. NAMES OF US OF 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND ING A DIRRETS On IROADS NEAREST TO Oft 13OUNDING THE OCTIO 8 ON LOCATION F WELLS OR WITHIN NINGOIPFiOPERTYE HUNDRED FIFTY FT. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND POSED STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. I ......i....................: ............:.....;.....:. ._. . .. .. .. .. '..__. .. .. _ .. .. ...:.......:..............:.............: .. .. .. ....... .. .. .. .. .. .. a .....:......:..........:..:......:....:.:.......... ....'.......:.......:..•...........:......•,............... .. ...............;. ..:... ..•...... ................�:... ....:.............. ...: _. °...t....;._. ................... ......'...........:;... .. ,. i.,....°.. ,. ...;.....i......,..........,...... ...............,...;............•, i I I DEPARTMENT USE ONLY Areas-- Date Dates_ Applleation Accepted By Dote Pump Inspection By Grout Irnpeetlon By �'� l Date Destruction Inspection By Comments: FACO AIDM ACCOUNTING ONLY: INVOICE DATE pERMITIBERVICE REQUEST NUMBER i PE CODE6 FEE INFO AMOUNT REMITTED CHECK+IICASH RECEIVED BY / t �