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PPLICAT16N FOR WELUPUMP PERMI- SAI ,AQUIN COUNTY PUBLIC HEALTH SEIES ENVIRONMENTAL HEALTH DIVISION: 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . ICBmpNI�In TtTplkatsl APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-17 16.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. I C , JOB ADDRESS/OftAPNf L1• CITY C�� PARCEL SIZEfAPNo OWNER'S NAME � ADOMeB nnl � � PHONE p CONTRACTOR ADDRESS LICR�PHONE[3 �Ug�p,F},y{CmR ADDRESH LIC/ PHONE TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL R ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑°CROSS-CONNECT RAIR ❑ VAPOR EXTRACTION WELL 1 r , �: �O Naw❑RepeFr H.P. DEPTH PUMP SET/�FT. FIRST WATER LEVEL 1 � RYPE OF PUMPI � � . . ❑ OUT-OF-SERVICE WELL ❑,GEOPHYSICAL WELL# ❑ SOIL BORING ❑13EBTFlUCTION: - tINTENDEb USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS - A ❑ INDUSTRIAL '.❑OPEN BOTTOM DIA,OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO b ❑ DOMESTICIPRIVATE ❑GRAVEL PACKt817E TYPE OF CASINOlS7EEt1PVC - DIA.OF WELL CASINO ❑ PUBLIc)muNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION IRRIOATIONIAG ❑OTHER GROUT BEAL INSTALLED BY GROUT BRAND NAME F" ❑ MONITORING - GROUT SEAL PVMPEO: ❑Yee ❑No CONCRETE PEDESTAL BY DRILLER:❑Ya. ❑No S APPROX.DEPTH - LOCKING CHESTER BOX/STOVE PIPE PROPOSED CONSTRUCTFONIDRILUNO METHOD! MUD ROTARY AIR ROTARY AUGER CABLE OTHER- I HEAEDY CERTIFY THAT I HAVE PREPAREb THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOADUIN COUNTY ORDINANCES,STATE LAWS,ANp RULE REGULATIONS OF THE SAN JOAOUfK COUNTY, HOME OWNER OR LICENSED AdENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR yVF11 THIS PERMIT IB ISSUED,1814ALL NOT EMPLOY PERSONS SUBJECT TO WoRKMAN'S COMPENSATION LAWS OF CALFFORNFA.' CONTRACTOR'S HIRING OR SUR-CONTRACTING SIGNATURE CERTIFFE THE FOLLOWING: 'I RTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN-11 COMPENSATION LAWS O� CALIFORNIA.' INE T UST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRED'INSPEC O I�rAT.1"61 408-3422. COMPLETE DRAWING AT LOWER AREA 1'ROVIVED. Blpnrd Tltle ✓ Data / r� PLOT PLAN(Drew to 806161 Beale 'to 1, NAMES OF STREETS O ROADS NEAREST TO OR BOUNDING THE PROI`ERTY.� 4. LOCATION OF 11008E SEWAGE 018POSA1 SYSTEM OR PROPOSED 2. OUTLINE OF THE PRO RTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAOE DISPOSAL SYSTEMS. 3. btMENStONEe OUTU S AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. 4 STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. tE LIE "a .,.. ..,.. ... .. .;.. ...: IIS � .�..._,.....,, .. ... ...�. .............._. :_.._;-. -_-.. ..,. i... ., .. .. ., ., .. k ...,. ...,.. .. ... JUS 2 X99 sora Ii�ARUl14 c u Ty EATH DIVISION: .fiIISLIC�iE�:LT ENVIRONMENTAL H DE ARTMENT USE ONLY ��6�6�6e�_,�,n-.,� -��srs-�n.--.. :�. r +: ._ -_ -.__1..��_�,-� -.�.... - - -s-rn-- - ,. —`•-.a.-.... :�.. _��• -- -ar!�;:r.m�r Apppeetlen Accepted BY ' /�..�+c l beta .Z Arae (I a' Grout Irtope0tlen By Date Pump In6P6ctlon of�,�i7 Date 22 ii Ooanellen Inrn6etl0n 8Y - Date Cemmmt+: _ ACCOUNTING ONLY: AID# :k FACat - SPE CODES FEE INTO AMOUNT REMITTED HECK ASH :. RECEIVED 8Y DATE PERMITISERVICE REQUEST NUMBER INVOICE I Pub.Health Serv.-Enviro.173(1197) ' fk