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'APPLICATION FOR WELUPUMP PERM SA )AQUIN COUNTY VJBL4C.HEALTH SEI ;ES ENVIRONMENTAL HEALTH DIVISION ' _- 304 EAST WEBER AVENUE,STOCKTON, CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED v (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAOUW COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WTI#SAI: JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLICHEALTHSERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORES"R A�{Py�N`/ �(/M i/ CITY G--p�//�1 PARCEL SIZFJAPNP Apt//5 - OWNER'S NAME w H IL eQ( ADOIESB Z40 /✓P1 �J( (/"KIK (C CA PLIONE/ _. CONTRACTOR _nl//:I''�nj �k.� ADDRESS rO Tlor 2r2 LIC/ PHONE# 707 93r4� FUS CONTRACTOR [�I'f aQ ADDRESS /f/&4rA. /L� r �v o /r�r� IJcr PHONE# 3/3-S�✓ TYPE OF WELLJPLOAP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORINO WELL 1 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ❑N•w❑Rood. H.P. DEPTH PUMP BET FT. FIRST WATER LEVEL rTYPE OF PUMP# tL��❑ CI /OUT-oF-SERVICE WELL ❑ GEOPHYSICAL WILL 1 l8 BOtI SORINO � ❑DESTRUCTION- INTENDED USE TYPE OF WELL. CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING r ❑ DOMESTICPgVATE ❑ORAVEL PACIUSIZF TYPE OF CASING/STFELPVC DIA.OF WELL CASING D ❑ PVBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION F ❑ W"GATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME F ❑ MONTORING OROLFT SEAL PUMPED: ❑Y•• ❑Ne CONCRETE PEDESTAL SY DRILLER:❑Y« [IN. .s APPROX.DEPTH (QD LOMINO CHESTER BOX/9TOVE PIPE PROPOSED CONSTRUCTIONWPILUNG METHOD! MUD ROTARY AIR ROTARY AUGER CABLE OTHER C- 1 HEIIEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND RULES ANI+ REOULATIONS Or THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SKTNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR W111C` TWO PERMIT IS ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'9 HIRING OR SUR-CONTRACTING SIGNATURE CEFTIr1ET THE FOLLOWING: 'I CERTIFY TH T IN TIE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'P COMPENSATION LAWS 01 CALTFORMA.' THE APPM URS IN ADVANCE FOR ALL REOUIRED INSPECTIONS AT 12081 406'42!. COMPLETE DRAWING AT LOWER AREA PROVIDED. BI,.r.A x ,eY TIt1• PLOT MAN#Drew to Sod•1 Sad• 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY 4. LOCATION OF HOUSE SEWAGE D19POSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PFIOPEIIrY•GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLSNF.S AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADW9 OF ONE HUNDRED FIFTY FT. STMnTUWS,IICUMMOO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PAOPERrY OR ADJOINING PROPERTY. ... .. .. ...... . .- - .: .... // .. ,....... L .. DEPARTMENT USE ONLY 7 faPPNe•t1•n Aeeaer•d Dr Det• / O �I A.— G..'.M»eea4—Br Owe Pump 1-0-0—By DNe De•tnctlen frweeefisn By D ACCOUNTING ONLY: AID$ FACS PE CODES FEE INFO AMOUNT REJWTTED CHECKSICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE Put-Health Serv.-Envirc.173(1/97)