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fjA APPLICATION FOR W 1.11PUMP PERMIT } SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICLY ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, M EAST WEBER AVENUE,STOCKTONe CA 95201388 (xas) 468.3420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM RATE ISSUED FILE co (Complets i6 TrlpNmHsl d ,.APPLICATION IS HERE RY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION RS MADE IN COMPLIANCE WITI4 SAN JOAQUIN COUNTY DEVELOPMENTTITLE,CHAPER9- 115.3AND THE NNDARDS Or SAN JOAQUIN COUNTY PUUBLICCHEALTH SERVICES,ENVIRONMENTAL HEALTH DVSION. JOS AODREsmn APNI R k � WAL !N-ur GtzavF k. CTv, '// Ox -,45�- on � PARCEL BiZEIAPNI OWNER'S NAME ADDRESS c44, PHONE I ]Q CONTRACTOR ErT 120 5 s - AbORE68 ��C! LIC/ S FHONE M3 3 Y_[�� �. SUB CONTRACTOR ADDRESS UCI PHONE/ TYPE OF WELI�P__UMP: ❑ NEW WELL ❑ REPL.ACEMENT WELL ❑ MONITORING WELL X ❑ OTHER ❑ RVSTALI.ATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL N ❑New❑Rep Nr H,P. DEPTH PUMP SET FT. FIRST WATER LEVEL p (TYPE OF PUMPI ❑ OU/T--or�SERV/ICE WELL ❑ OEOPTIYSICAL WELL 41 ❑ SOIL BORING �7 DESTRUCTION: 0 It-wT AoEt)a ��c� �� _ R INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4 ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO If ❑ DOMESTM/PRiVATE ❑GRAVEL PACKISIIE TYPE OF CASINOISTEEL/PVC DIA,OF WELL CASINO p ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R pp ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME f 4 ❑ MONITORING GROUT SEAL PUMPED: ❑Yr ❑No CONCRETE PEDESTAL BY DRILLER:[IV. ❑Ne S !!!!� APPROX,DEPTH LOCKING CHESTER BOXISTOVE PIPE 8 I PROPOSED CONSTRUCTIONIDRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER_ r 1 HEREBY CERTIFY THAT I IIAVE 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 AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:`I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,' CONTRACTOR'S HIRNO OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WDRK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." T PPUC :1o:MKILPT CALL 24 HOURS 1N ADVANCE FOR ALL REQUIRED INSI ECTION�S^AyT�1200)400-5423• COMPLETE DMV41HO AT LOW£R AREA PROVIDEO. Slgrred X — Title QWA-- /L PLOT PIAN(Mew to Seetel Seals 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING TIIE 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• xbC� its' �✓ A :. I . Y i� .. J. - )fir ,...................VIR Af €Ai Tl C :... . ....... . .........: t NVI�tbNMFNT...;......:.....::.....:......:.... _ DEPARTMENT USE ONLY Oroue Inepeatton$y Dete Hm�P Irodeetlon By Osle Deettwilen Inedeetlon By � D.te `3 +' f t.T/.Y�4.t.� 38 0{-� S..s•�{�e.cG. OSltir,,�,egl GaO� / ACCOUNTING ONLY: A1bR FACR I v -s�,r t.aQC•p�r 3 PE CODES FEE INFO AMOUNT REMITTED CHFC ICASH RECEIVED BY PATE PERMITISEAVI E REOVEST NUFARM INVOICE v p 3 5� Pub.Health Serv.-Enviro.173(3196)