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puml APPLICATION FOR WELUPUMP PERMIT WELL SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ELL pU' M • ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NDN•REFUMBLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Mempl.tf In TTIpnentel APPLtCATkON 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WTTII SAN JOAQUIN COUNTY DEVELOPMENTT TITLE,CHAPTER 8-11115.3 AND THE BTANDAROB OF SAN JOAQUIN COUNTY PUBLIC IIEALTI!SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOS ADURESS/OR APN/ (r CHy G{C• irJS} [�zEIAPN/ p 3- c7- 1 OWNER'S NAME ,�.,� n (]Q,1 �.n[t ADDR�ES�Sr S �n �L— —1 PI-I(TNE F 20�j f -/9LI91 C ONT TVIC TOR�� V r!i r* Yi'l L�T�1NL�C `�1 1`iOVr�.�4•u�i] � [7C>-,�f-8I8'��r'- I SIO S27LIC/ �~ PHOHE 7Yt Z-S� 4 1 GUSCONTRACTOa Qn/ E 3 J �' mea�� SocC C!/ uC/ss q� TYPE OF WELLIPVMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 4 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROS&CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J A YPE OF RIMPI 13N.❑R.prr H.P. DEPTH PUMP SET FY. FIRST WATER LEVEL O ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ROIL BORING C.� p l INTENDED USE TYPE OF WELL CONSTRUCTION fPECIFICATIOMS 4 A ❑ INDUSTRIAL ❑OPEN aOTTOM DIA.Of WELL EXCAVATION (r DIA.Of CONDUCTOR CABIN /AYH 1 ❑ DOMEBTIClPR1VATE ❑GRAVEL PACICI8QE TYPE Of C ASING/BT EELR'VC !�I- (�IA,OF WELL CASING O ❑ PUBLIC/MUNICIPAL ❑DRIVEN f DEPTH Of GROUT SEAL ,1'ti- ff f ^jFfCIFICAFFON R ❑ IRRIOATK)NIAG /I-OTHEA (9co-k 1 GROUT SEAL INSTALLED BY /l F �' GROUT BRAND NAME E 'Rr19}MTO/YNG GGd OROVT SFAL PUMPtO:pr'yi. ❑N. CONCRETE PEDESTAL BY DRILLER:❑Yee 0 5 APPROX.DEPTH LDCKWO CHESTLR BOXISTO VE PIPE S PROPOSED CONSTRUCTION/DftLLINO METHOD: MUD ROTARY_AIA IDTARY AVOER �< CABLE OTHER 1 HEgEBY CERTIFY THAT I HAVE PREPARED THIS APPMATIQN AND THAT THE WORK WILL SE DONE*1 ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REOUEATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINGS 'I CERTIFY THAT IN THE PERFOPIMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL NOT EMPLOY PERSON@ SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.* CONTRACTOR'-HIRING OR SUB-CONTRACTMTG SIGNATURE CERTIFIES THE fOLLO RTIFY THAT ML THE PERFORMANCE OF THE WORK FOR WHICH THIS PERM T IS 188VED.1 SHALL EMPLOY PER80N8 SUBJECT TO WORKMAM'S COMPENSATION LAWS OF CALUFORMA. HEA A UST ALL I4 HOVRS IM ADVANCE FOR ALL REQUIRED IMS !IDMS AT 12081460-1423, COMPLETE DRAWING AT LOWER AREA PROVIDED. T— -} SIVwd X TItI. ��- Dal._S G S�� G Ii ROT PAM(Dr—to Sor.l Bar. to 1. NAMES OF 9TREET8 OR ROAD.NEAREST TO OR SOUNDING THE PRDR4RTY. t. LOCATION OF MOUSE SEWAGE DISPOSAL SYSTEM OR PLOTSOBED 2. OUTLINE OF THE PROPERTY,GIVMIG DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYSTEMS. 2. DIMENSIONED OUTLWF.S AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HONORED FIFTY FY. STMXTVI4M,M+CLUDINO COVERED AREAE SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. (� I NO Ci-HEMIq L TESTING MA P JB1 JG SANJtl�1�1[TI�CtllflV I r NYOOW',i�AL ilE4 RN DtVsldFa GEOTECHNICAL ONLY: DEPARTMENT USE ONLY 2 L AapHa.tlen Aaaept � Du. � �U hr V G.a A IMpeallen BY b.ta Amp Impeellen By D.t. Ow.In�Nen I—p.elFon y Date `j- V C er.emenea: / / ACCOUNIM11 ONLY; AHD/ FAC/ PE CODES FEE INFO AMOUNT REMITTED RECEIVED BY DATE PER48TfSERVICE FEOVEST MUM8EHT INVOICE 3 as .:r