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APPLICATION FOP 'UMP PERMIT '+eAN JOAQUIN COUNT.,., ;i C HEALTH SERVICES► ENVIRONMENTAL HEALTH DIVISION P.O. BOX 3881304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (2091489-3420 NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED �� ICemplet{in TripDalel APPLICATION IB HERE BY MAGE TO THE SAN JOAQUIN COUNTY FOR A Copy PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.E AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESWOR APNO / ^w G}-1�2►E2 '^�4� crr+ PARCEL BIZFJAPNI S`TC!C-k 1��/ OWNER'S NAME wdd� Y V �' CyC. 166 �^t2�k^� �A/ i`T CI Lt p t ADDRESS :L5 KTf� 2(? —YQQ�YPHONE T. 8-9grai CONTRACTOR�[SC# t�Vl�{dNr'++ r�rq` ADDRESOV NI RP ^/Gg�s2r;z L)Cs6S38G5 PHONE T{,2-3S�7O R _ ADDRESS LICS PHONE S TYPE OF WELL/PUMF- ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ (TYPE OF PUMP) ❑NOW❑ReP.w H•P• DEPTH PUMP SET FT. FIRST WATER LEVEL Q O i-1 ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL a Sort BORNro J e 0 DESTRUCTION! INTENDED USE TYPE OF W111 CONSTRUCTION{PECIFiCATiON{ ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 211 A GIA.Of CONDUCTOR CASING p ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC OIA.OF WELL CASING O PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME 13 E MONITOWNO _ GROUT SEAL PUMPED:❑Ys ❑He CONCRETE PEDESTAL BY DRILLER:❑Yr [IN. S APPROX.DEPTH 90 F T LOCKING CHESTER BOX/STOVE PIPE 11 S PROPOSED CONSTRUCTIONRXRILLINQ METHOD: MUD ROTARY AIR ROTARY AUGER CABIE OTHER.IJI 4eCL 1 PVS I HE9ESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS Of THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•t CERTIFY THAT IN THE PERFORMANCE OF THE WORC FOR WHICH THIS PERMIT IS ISSUED I SHALL NOT EMPLOY RSO NS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HI OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: CE IFY THAT IN THE RMANC OF TN RIC FOR WHICH THIS PERMIT to ISSUED,i BHALL EMPLOY PERSONS SUBJECT TO WORKMAN'!COMPENSATION LAWS OF CALIFORNIA.' T APPLI ANT MUST C 4 HO`� LL REOUIRED INSPECTION{AT 120{!4ee,422. COMPLETE DRAWING AT LOWER AREA P10 to 8lpned X TTe.R6 Stiff D„.3 PLOT PIAN(Do~to goal.)Sed. 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED MO 2. OUTLINE OF THE PROPERTY,GIVING OIMENNS AND NORTH DIRECTION. EXPANSION OF SEWAGE OISPOSAL SYSTEMe. 7. DIMENSIONED OUTUWF.S AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. !.. ..i......?. ... fill .. .. _ .._ .. .. ... :. . ...:......!.......[....5... .. _ . ..:................. i... ..._. - ...............:...... vvAmwEN7 USE ONLY Apolleeton Aee.oted By bolts Greet,i�epeelient By O„e Pu o In oeetlen By •_Ostnwtbn In.ostbn By - Dots ..Gerementr vets ACCOUNTING ONLY:- A/DS - - FACS 1'E CODE! FEE INFO AMOUNT REMITTED CHECKS/CA{” RECEIVED eY DATE- PEENMt!{E NICE REQUEST NUIMISEL 35o INVOICE Pub.Health Serv.-Enviro.173(3/96)