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4. APPLICATION FOR WELUPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I' ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 �Q py NOTE-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cem0ste In TrIPBtlels) APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.TI118 APPLICATION IB MADE IN COMPLIANCE WrTlf SAN JOAQUIN COUNTY DEVELOPMENT TTTLE.'CHAPTER 9.1119.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH OrASION. JOS ADOREtlSA7R APH# !/ CITY r^ �] v PARCEL SIZEJAPN8 3z— OWNER'S NAME rC�'Lcls.,aAq Stl qC/a V I��J PHONE K (3 !^OCV Z'2 CONTRACTOR ~`��--+ �-��r� C O Cf ADDRESS T'` tJCI,1G 3 73 PHONE I Bub CONTRACTOR••••- ADDRESS UCI PHONE TYPE OF WELUPUMP, ❑ NEW WELL i� ❑ REPLACEMENT WELL L.1 MOIwORNO WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL S STEM REPAIR ❑ CRO88-CONNECT REPAIR ❑ VAPOR EXTINCTION WELL Al J 14 I , ❑New©Repdr H.P. �I '1__. DEPTH PVMP BET ^FT. Ftt18T WATER LEVEL lJ O� rTVPE OF PUMPI i� ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL 8 ❑ SOIL SORNG 8[ } ❑DESTRUCTION: i INTENDED USE TYPE O WELT CONSTRUCTION SPECIFICATION& A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION OG.OF CONDUCTOR CASINO O� ❑ DOMESTI mmATE ❑GRAVELIPACKIBRE TYPE OF CASINOISTEEUPVC DIA.OF WELL CASING VON ❑PUBUCIMUNMIPAL ❑DRIVEN I DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATWNIAG ❑OTHER I GROUT BEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING I GROUT BEAT PUMPED: ❑Yr ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yr ❑Na 5 APPROX.DEPTH LOCKING CHESTER BOXA#TOVE PIPE S �s PROPOSED CONSTRUCTIONIORLUNG MiIITHOD; MUD ROTARY AIR ROTARY AUGER CABLE OTHER II I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL bE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND IIEPULATKTNS OF THE SAN JOAOVN COUNTY. HOME OWNER OR LICENSED AGENT'S BIONATLME CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PEW*RMANCE OF THE WORK FOR WHICH TH16 PERMIT 18 ISSUED,I @HALL NOT EMPLOY PERSONS SUBJECT 70 WORKMAN'S COMPE86ATM"LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUII-CONTRACTbro SIGNATURE CERTIFIES THE FOLILOWNO, 't CERTIFY THAT IN TIIE PERFORMANCE OF THE WORK FOR WHICH THIS PERM T IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOVIMAAN'f COMPENSATION LAWS OF CALIFORNIA. 7� / "CANT�M' MTCALL 24 HOURS IN ADVANCE FOR ALL REOUR�ED IN>11rWTIONS AT 120014W442*- COMPLETE DRAWING AT LOWER AREA PROVIDED. YI^sN On. i.t -� i PLOT PLAN Skew to Bade$Bede 'to - --— 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING TINE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIBPOBAL SYSTEMS. 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXTWMM AND PRDPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY PT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, l PAYMEN RE EIVF v i- '1 JUN 3 0- 1998 I0AN:JOaC1LJIN Cf3ONTY ENVIRON ENTAL HEALTH&DIV StC)p l .e DEPARTMENT USE ONLY App11ee11en Aeeepled BY (I e Mee 4 C f/L Oreut Irmpecllon ev II to Rfmp Impaction by s Dole Lr �vc Deolne Oon Impeel,en BY .!I - Date CemmeMo: II E] II i ACCOUNTING ONLY; iiAID# FAC# 1 PE CODES FEE INFO AMOUNT REMITTED CHECK# AS" RECRVED By DATE P91MITNERVICE REQUEST NUMBER INVOICE IM ' II'E Pub Health Serv.-Enviro.173(1197)II