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` r PPLICATION FOR WEWPUMP PERM'` )... _ OSS-OSS GDI <br /> SAI%-JAOUIN COUNTY PUBLIC HEALTH SEh,...;ES <br /> ENVIRONMENTAL'HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209)468~3420 FILE <br /> OON•REFUNDABLE•PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete In TrlpiieEt�) <br /> APPLICATION BB HERE BY MADE TO THE SAN JOAQUIN-COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR 1N6TALL THE WORK DESCRIBED.THIS APPLICATION 18 MAGE Ik COMPUANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE.STANDARDS OF SAN JOAQUIN COU/N�T`Y pUBUC tH�EA.LTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, <br /> JOB ADDRESSA)R APNI a�,_� Pj SC CITY G S y.. PARCEL 812ElAFFJr <br /> OWNER'S NAME !"UCLA r <br /> - <br /> PHONE <br /> CONTRACTOR C? /�1�w1 ADDRESS y-"/7T" UC/'SJ i2 PHONE r <br /> OUR CONTRACTOR ADDRESS � ^ UCr PHONED <br /> TYPE OF WE,LLpump. ❑ HEW WEU_ ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> 4 ❑ INSTALLATION ❑ WELL SYSTEM REPAIR' ❑ CROSS-CONNECT REPAIR <br /> 11 VAPOR EXTRACTION WELL r <br /> 13New 11�alr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 6 <br /> (TYPE OF PUMP) sJ��y/ <br /> ❑ OU-0 <br /> TP-8ERVICE WELL 13dEOPiYBICAL WELL#_ SOIL BORING / rAgo <br /> ❑DESTRUCTION- <br /> i <br /> IIli�"tIENbED U8E TYPE OF WELL CONSTRUCTION SPECIFICATIONS ,4 <br /> LJ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO A <br /> ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINOISTEELMVC OFA.OF WELL CASINO b <br /> ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER OROUT SEAL INSTALLED BY GROUT BRAND NAME C g <br /> ❑ MONITORING (TROUT SEAL PUMPEO: ❑Y. ❑No CONCRETE PEDESTAL BY DRILLER:fly. [IN. S <br /> APPROX.DEPTH LOCKING CHESTER SOXIBTOVE PPE <br /> S <br /> PROPOSED CONSTRUCTIONIDWLUNO METHOD: MUD ROTARY AIR ROTARY AUGER- CABLE OTHER_ <br /> I HEREBY CERTIFY THAT I I4AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 19 ISSUED.I SHALL NOT EMPLOY PERBONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: ERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH T14I8 PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WOAKMAN'e COMPENSATION LAWS OF <br /> CALIFORNIA.- YWAkImIXANT MUST C (IRE t ADVANCE FOR ALL REQUIRED INS=12001 4604423. COMPETE DRAWING AT LOWER AREA PRO OED <br /> �R 4 <br /> Blrned X �� Tlil. Data V / <br /> E <br /> E <br /> PLOT PLAN(Draw to Beale)Beate 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOV8E SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF BEWAGE DISPOSAL SYSTEMS. <br /> 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED - S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> :.E . <br /> .. <br /> . c <br /> t . <br /> . <br /> l" . <br /> - UN-P <br /> �kP�J <br /> �F"AWIC6S <br /> DEPARTMENT USE ONLY <br /> Appileatlon AeeeMed By - <br /> Dal. <br /> Grout Inspeotlon By D.t. Ptwnp In.gaetlen By rI^ Dote 't. <br /> b,ntruetlen I—rocilan By Vi L Date ow <br /> r <br /> f I <br /> Cem-"Ot <br />` 1 <br /> ACCOUNTING ONLY; AIDI FACI <br /> I <br /> PE CODES FEE INFO AMOUNT REMITTED CF ASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBEt INVOICE <br /> 3 I <br /> Pub.Health Sely.-EnvlrG.173{1187} <br /> �d � <br /> W% <br />