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DPLICATION FOR WELLIPUMP PERMIT" SAN _...,AOUIN COUNTY PUBLIC HEALTH SES.__.:ES O ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 MDR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompUtr In TtI licstel APPLICATION IS I4ERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAFTER 9.1-1y15.3 AND THE STANDARDS OF BAN JOAQUIN COUNt�'YjPU,9LIrC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. �] JOB ADDRESSIOR APNA' i•� 12- l:�'T �� CITY S i lL_.•V ��L`�/ ._,.._PARCEE SIZEIAPNA' �1 OWNER'S NAME O^^S^� ADDRESS X9,4 A4 t- / PHONE' 7 _4/� CONTRACTOR C W rr r lC L ADDRESS + C C h&�r1`�V'Jcr2260 PHONE R- -ll SUB CONTRACTOR ADDRESS LJCi PHONE/ TYPE OF WELLMUMP• I] NEW WELL PLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ji P ❑ INSTALLAT ❑ WELL SYSTE REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL A ,! ❑New eir H.P.�� DEPTH PUMP SET FT. FIRST WATER LEVEL p i (TYPE OF PUMPI ' ❑ OUT-0F-SERVICE WELL ❑ OEOPHYBICAL WELL# ❑ SORL BOIUNG a ❑OEBTRUCTION: INTENDED USE TYPE OF WELL CONSTFIUC 1ON SPECIFICATIONS nr� 1r A 13 INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION G DIA.OF CONDUCTOR CASING D 11 ��d-� S/ DOMESTIC/PRIVATE 9 'ORAVEL PACKlBIZE 2-1 TYPE OF CABINGlBTEELlPVC S ��-� ,_,_• DIA.OF WELL CASINO �1 b �❑,--1,�PPU^BLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL /��,/�/ SPECIFICATION-�7/Y� 51924-2 9.�C F ' LdIRRIGATIONIAG ❑OTHER OROUT SEAL INSTALLED BY (A K-- GROUT BRAND NAME ��1924 . @ ❑ MONITORING GROW BEAL PUMPED: UM [IN. CONCRETE PEDESTAL BY OWLIERI Y.FVer ❑No` S AppROx,DEPTH LOCKING CHESTER SOXMOVE PIPE S PROPOSED CONSTRUCTIONIBWLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1-/ 1 HE'Wly CERTIFY THAT T IIAVE PREPARED THIS APFLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE 1MTH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIONATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF TIIE WOW(FOR WHICH THIS PERMIT IS IBBUED,I BI4ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,- CONTRACTOR'S HIRING OR SUB•CONTPU1CTING SIGNATURE CERTIFIEB THE FOLLOWING: -I CERTIFYIN TIE PERFORMANCE OF THE WOWS FOR WHICH THIS PERMIT 10 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." T M S 4 HOUR 1 ADVANCE FOR ALL REGUTRED INSPECTION S /ATS]120�1914efa4�23 ]COMPLETE DRAWING AT LOWER AREA PROVIDED. Bland X /4.� T111eC.C[V/ AVL+C-C.z/ ...... Date PLOT PLAN Rkwv to Seelal Seale 'Ie 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 FROPERTY,OWING D1MEN8ION8 AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B_ 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. 91. I 'y. I i w� o .6 .............L' .. . ;SU1v N . ..9 1 .. r -T -.---_"'.,DEPARTMENT UBE ONLYput._ "='�....� _ � Eft";.AL.Nf✓S.i p f}fes... It Apolaeliwt Aeeapted By 4ete Area I � Grout Irnpeetlen By Dete U pInapeeUen BY Dele 13"Irt ellen Irnpel `allonn By Date 460 Ce/,t ' i 1 u ec� 6 of ' p6v ea ! Ca rn CCW a AOUNTING ONLV- AID/ FACTMI PE CODES FEE INFO AMOUNT RETTED HEC ICASH RECEIVED NY DATE PERMITISEAVICE REQUEST NUMBER INVOICE D 6D Pub.Heefth Serv.-EnYirG.173(1187) K