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MAR 2 91999 APPLICATION FOR WELLJPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES . ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 i;+'!;r 7 "= (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED (Cempkti IB Tr1pReits) APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED,THIS APPLICATION IB MADE IN COMPLIANCE WfTH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8.1 1 1 5.3 AND THE STANOARDS OF SAN JOAQUIN COUNTY PU''BfLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORES.. PHI — D ) CITY � 7 b/�C LPARCEL SIZE/APNJ OWNER'S NAME l (/O�1yW�I, I K)n ADDREBB G� U V )C IIS f �7 PHONE smq z-' ??q-201 CI CONTRACTOR \ �C'1] 'i G7 -TAOORESS n I 1 ii SVB CONTRACTOR ADOREBS Lics PHONE F TYPE OF WEL.UPUMP7 (3NEW WELL ❑ REPLACEMENT WELL MONITORING WELL• I •iN ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSB-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑Naw❑RW k H,P, DEPTH PUMP SET F7. FIRST WATER LEVEL O - (TYPE OF RUMP! B ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL F LI SOIL BORING ❑QESTRUCTIONr INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ IMM67NAL 0 7/OOPEN BOTTOM I� VIA.OF WELL EXCAVATION VIA.OF CONDUCTOR CASINO N O ❑ DOMESTICIPRIVATE �.RAVEL PACK7SIZE! ✓ TYPE OF CASINO/STEEL/PVC 1l DIA.OF WELL CASING (� O Cl pVBL1C/MUMCIPA! ❑DRIVEN DEPTH OF GROUT SEAL 15tl,"4 �� FP2 T SPECIFICATION &141261il2 7 it R ❑� IGATIONUAO ❑OTHER GROUT SEAL INSTALLED BY 9Q GROUT BRAND NAME G r N E RRI MTORING GROUT SEAL PUMPED: Ye• [IN. CONCRETE PEDESTAL BY DRILLERAY- ❑Ne S APPROX.DETTH ../S 2"F"T !-/'��V LOCKING CHESTER BO O RPE L� S PROPOSED CON@T1RICTIONRMtUNO METHOD: MUO ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I NAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOIIRI COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOW1NGi'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'@ HIRING OR SUB-COHTRACTRM MGMATURE CERTIFIES TNS FOLLOWING: 'I CERTIFY THAT IN T11E PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 10 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WONWAN'S COMPMBATION LAWS OF CALIFORNM.' RIE APPLICANT MUST CALL 24 IN ADVANCE FOR ALL REGUMED;lNgZTIONS AT 12001 4ii44 C_O/MPLEETE DRAWING AT LOWER AREA PROVIDED. , Date PLOT PLAN(Drew to 9-0101 80.19 'to 1. NAMES OF STREETS OR ROAD NEAREST TO OR BOUNDfM THE PROPERTY. A. LOCATION OF HOUSE SEWAGE q SYSTE SYSTEM OR PIt01'06EO 2. OUTLINE OF THE PROPERTY.Gt%*M OWENSIONB AND NORTH DIRECTION. EXPANSION F SEWAGE VI Wn"N pA SYSTEMS. ]. DIMENSIONED OUTLINES AND LOCATION OF ALL EXIBTING AND PROPOSED S. N THE PR OF WELLS ADJON rtAD1U6 MI ONE HUNDRED FIFTY FT. STRIUCTVRE$,INCLUDING COVERED AREA$SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJDBAPKL PROPERTY• AD 0 VfD j. r C r• D ARTMEf+r USE ONLY NM AppBeetten AmWted By i I Dole O—A Impeetlon or D•t Pump Impeetlen By O•t• O-I'mil•n I—peetlan BY 1 D•1• CemmelN•: ACCOUNTING ONLY. AIDS FAC/ PE CODES FEE INFO AMOUNT REMITTED CHECKffCASH R C BYI /f DATE PErMlISERVICE REQUEST NUM$BI INVOICE .0 Pub Health Serv.-Enviro.173(1/97)