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r APPLICATION FOR WELLIPUMP PERMITI� {+�v� l{� SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES jj��lilll ENVIRONMENTAL HEALTH DIVISION JUN P 0 BOX 388,446 N.SAN JOAQUIN ST.,STOCKTON,CA 96201.388 2 6 1995 (209)468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH, lcomp6t4 in Tiipliau) PERMIT/SERVICES APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMITTO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER )9--111 6.3}A�N,,D T.H1E.STANDARDS OF SAN JOAQUIN COUNTY PUBLIC /HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION.2-50 JOB ADDRESSOR APN. /679 t t 114"` S I-r CITY-q�ro-,, l •-�' /'� PARCEL SIZFJAPNO �.Gy� r OWNER'S NAME .`Vr. r fl. -Llny-Ac ADDRESS F6, , 611 Icf-AX . `--'' q"�+ PHONE42O� 4/(d� CONTRACTOR ��`1I�F�Y\r�Yj�P-�'S!_� °�� ADDRESS l7io �7I�\I�J.{ FYI n LIC q()g pPHONE/ c��J✓�-"'� SUB CONTRACTOR--'1[�C�CF1'_.1/�Yb� L71EYr+-lCrUr ADDRESS GF1R�N'iW`^ L1Cf�-JI`-T{/D PHONE I /-Ill TYPE OF WELUPUMP. JL�1�NEW WELL 1 ❑REPLACEMENT WELL .G`L MONITORING WEELLT4# 1.2-G ❑OTHER /s INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAJR' ! ❑VAPOR EXTRACTION WELL 1 J ❑Nw❑hpdr N.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑OUT-0F-SERVICE WELL ❑GEOPHYSICAL WELL 1 ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ^� / ,�./.� A ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION / ,ry DIA.OF CONDUCTOR CASING-- 1-^F^"^'- D 13DOMESTIC/PRIVATE GRAVEL PACK/512E TYPE OF CASING/STEEL/PVC LL 1.S L DIA.OF WELL CASING fh�V` D ❑PUBLIC/MUMCIPAL ElDRIVEN 21()�"'- DEPTH OF GROUT SEAL 41 �'L.11�� SPECIFICATION S( R ❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY 5:-W- Tim GROUT BRAND NAMEE MONITORING GROUT SEAL PUMPED:XYw [IN. CONCRETE PEDESTAL BYDRI,LL�FR:❑Y. No S APPROX.DEPTH 7LOCKING CHESTER BOX/STOVE RPE �4t IXV'f I +--(f—V%-*EL, S PROPOSED CONSTRUCTION/DWLUNO METHOD:MUD ROTARY AIR ROTARY AUGER Vf CABLE OTHER IMEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK 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 AGEM'S SIGNATURE CERTIFIES THE FOLLOWING:'i CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECTTO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.'CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' NE C M`�'T CALL K HOURS IM ADVANCE FOR ALL REQUIRED INSPECTIONS AT(308)488J43].COMPLETE DRAWING AT LOWER AREA PROVIDED. Sior»a X TIll...�T`�-� � �1'- D.I. Ob PLOT PLAN(0—to Su*)Sub 'to 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ... ....:... .. DEPARTMENT USE ONLY I ApPSution Acc.pt.d By O.ta Arw Grout Inpac[ion Sy D., - PIanP lmpwtlon By D.t. Dwtructi.n I�.etion By D.<. Comm.,t.: I 1 ACCOUNTING ONLY: AID. FACS DECODES FFIEEINFO &� V AhlOUNTREMITTED (V O 1CHHECK//MMI RECEIVED BY D�A1TE ► IT/SERVICE REQUEST NUMBER INVOICE YL 50 (