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APPLICATION FOR WELLIPUMP PERMIT iN JOAOUIN COUNTY PUBLIC HEALTH SERVIC ENVIRONMENTAL HEALTH DIVISION P.O. BOX SW 304 EAST WEBER AVENUE, STOCKTON, CA 95201 88 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED i {CompMta In Triplieit@l APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. c JOB ADDRESSMR APNI CIT/Y®_ JIt](T1 - PARCEL SIZEIAPN# S -- OWNER'S NAM 4940 ADDRESS /A / ^ 1 r / PHONE CONTRACTOR /A• ' t /fir ADDRES8 CI,/GQ eZ- PHONE#.S•'��Z--fJ`'2� SUB CONTRACTOR ADDRESS LIC# PHONE# TYPE OF WELL/PUMP: 17 NEW WELL REPLACEMENT WELL ❑ MONITORING WELL# © OTHER © INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL i J ❑Naw❑Repdr H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL O (TYPE OF PUMPI D OUT-Cf-SERVICE WELL 1] GEOPHYSICAL WELL I ❑ SOIL BORING 8 / r DESTRUCTION: P 1 SS INTENDED USE TYPE OF WELL CONSTRUCTION 001FICATION8 dr. A 13 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO 0 9-1ROMESTECIPRIVATE �jtG AVEL PACKISIZE TYPE OF CASINOISTEEUPVC DIA.OF WELL CASING 96 f D ❑ PUBLIC/MUNICIPAL ©DRIVEN DEPTH OF GROUT SEALSPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL IN8TALLE1)8Y 1-f GROUT BRAND NAME E © MONITORING / GROUT SEAL PUMPED: Vr ❑No CONCRETE PEDESTAL B�R ❑Yr Ne 5 APPROX.DEPTH, r LOCKING CHESTER BO%!STOVE PIPE S PROPOSED CONSTRUCTIONIDMLUNG METHOD: MUD ROTARYC?L AIR ROTARY AUGER CABLE OTHER I HERESY CERTIFY THAT 1 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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.` CONTRACTOR'S HIRING OR BUB�CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL URS IN ADVANCE FOR ALL REGLXRED INSPECTIONS AT 12051 408442?. COMPLETE DRAWING AT LOWER AREA PROVIDED. g�J 8819"d '1. y Tltle s iA L 1 r QYt __ Dat.T� !fJ PLOT PLAN IDraw to Senile)Sc*o '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. ..,.., .,. ... .. f . J ..,..,... ..........:........ ...... .............: ...- .,, C.d ,.Jam? .. .. .-_ .. .. .. .1 Qk .. . ..,.. ..... . ... ... _ � - t JUL 2 3 1998 N '; .; SAN JUAt]IiIN GbUnli`r . 'L, _ ENVIH NM1/EM'f'AZ:HI=,AL-Tff'DIVISf I DEPARTMENT USE ONLY Apprlcatlon Accepted By. / "" �G Data 2—;2 if Area Grout Inspection By Vr t Onto G Pump In tion By Date Destruction Irnpactle P ] Data Comments: V` M1 1 41 ACCOUNTING ONLY: AID# FAC# �� V PE CODES FEE INFO AMOUNT REMITTED CHK ASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE SIJ ft tff0 f 0 s X1,317.3 00 gy-go - .c—