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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 95201388 (209) 4683420 � Aq EFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED J (A•L w (CampMd in TrolieEn) _ APPLICATION IS HEREBY MADE TO THE SAN JOAQ INC NTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED,THIS APPUCATION IS MADE IN COMPLIANCE WRH SAN lOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115,3 AND THE ST NDARDS OF SAN JOAQUIN C LINTY L E}��TJ�1..6ERVK;EB,E�y)VIRONMENTAL HEALTH DIVISION. W JOB ADDNESSMR APNJ 1- 3 V U.N�CI �a PARCEL SIZE/APNt �/� — OWNER'S NAME k ADDRES�C,�T X//� �� IZ-1.✓M Y r PHONE#59jjJ COMRACTOft ADDRESRY/ 9. jz- k O VCQ !7�F/�gIONE.ff��/ l SUBCONTRACTOR ADDRESS UCV f-�- = PHONE TYPE OF WELVPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORMG WELL.- 13 OTHEA Y ❑ INSTALLATION 13WELL SYSTEM REPAIR 1-1CROSS-CONNECTREPAIR 13VAPOR EXTRACTION WELL i J Iw✓ 111Nov RROPO, H.P. /FJ/J DEPTH PUMP SET�FT. FIRST WATER LEVEL_Z;-G, 0 RYPE F RIMPI ❑OUTOF-SERVICEWELL 11GEOPHYSICAL WELL. 13SOILBORING S ❑DESTRUCTION: INTENDED US __OF _LL T ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASING A 11 DOMESTIC/PRIVATE ❑GRAVEL PACK/512E TYPE Of CASING/STEFVDPVC DIA.OF WELL CASING 130 PUSUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R MONITO ❑ IRIN ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORINGG GROUT SEAL PUMPED: ❑Ym ONO CONCRETE PEDESTAL BY DRILLFR:❑Ys ONO .S APPROX.DERH LOCKING CHESTER BOK/STOVE PIPE S PROPOSED CON6T11UCTIONNRIWNO METHOD: MUD flOTARV AIR ROTARY AUGER CARIE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPMATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN"AMIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE E THE ,AND FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.• CONTRACTOR'S HIRING OR SUB-CONTRACTINGNCEOFSIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS CONTRACTOR'S SUBJECT TO WORKMAN'S SIGNATURE RE LAWS OF _ CALIFORNIA.' TXE Ap1BLGANT MUST CALL 29 t IN ADVANCE FOR ALL REQUIRED INSPECTS/L�'W( T/(2200110(448-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. SI..X✓✓✓/// — 0 Tltk_ Y' f l— S Gats s / PLOT PLAN(Dray.•to S Ia)6MIe •ro 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED — 2. OUTUNE OF THE PROPERTY,GIVING DIMENSK)NS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROMSED 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 PROMRTy. e ✓l•Jc t�/J� �ok�C � _ Is c C/ �\ ol -- _ � 1 v I � � s 3l7 //7 SEP 1 3 1995 ie vb 14i)TYI�' TFP.� DEPARTMENT USE ONLY G'..' tion Accepted 0Y ��L�'�e Data Am__ Grput Inpsnpn BY Pump Impectlpn BY4' Ul A pate L A Drtruptbn Lrpap[bn BY Dna �`� Gammen'.: L ........ONLY: Al.. FAC.ONLY: AID. FACT M CODES FEE INFO AMOUNT REMITTED L.HEC ABN RECEIVED BY GATE PWAT/SERVICE REQUEST NUMBER INVOICE ly , )b 173 1&' ci > i >3 rl �3 oaa9lo