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r-°'DPLICATION FOR WELLIPUMP PERMk--) SAK ... AOUIN COUNTY PUBLIC HEALTH SES.-...;ES Fly ENVIRONMENTAL HEALTH DIVISION n304 EAST WEBER AVENUE, STOCKTON, CA 95202 ��``--''JJ (209) 468-3420 NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplkatel APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOP/M�E14T TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOS ADDRESS/OA APN# L✓ 2�� c CN•y ,��1 r rL n- ?- PARCEL SIZE/APNN�2 LI 7�-0 OWNER'$NAME f��/� �.] ADDRESS 9,4 PHONE N 7 CONTRACTOR L CA r �C ADDRESS �'I!y�UCI ----PHONE B SUB CONTRACTOR �r�77 ADDRESS UC# - PHONE# TYPE OF WE! MP, ❑ NEW WELL. 1a4FLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER TjAEPA. ❑ INSTALLATI 11 WELL SYSTE REPAIR 13 CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ,I IY ❑Naw alr H.P. jr!} DEPTH PUMP SET FT. FIRST WATER LEVEL d (TYPE OF PUMP) T_ - ❑ OUT•OF-SERVICE WELL ❑ GEQPHYBICAL WELL I ❑ SOIL BORING e ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A' ❑ INDUSTRIAL 1❑�OPEN BOTTOM / DIA.OF WELL EXCAVATION__ DIA.OF CONDUCTOR CASING O ❑ DOMESTICA'RIVATE Q15 AVEL PACK/SIZE ` TYPE OF CAGING/BTEELIPVC_ DIA,OF NEL!CASINGf p I,�❑,... PPUBLIC)MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL /�rr SPECIFICATION 7�'/A 6 -f'/C R Ld' -MOATIONIAO ❑OTHER GROUT SEAL INSTALLED BY / GROUT BRAND NAME_ rS�LT'-1 ' - E I9 ❑ Moml-ONG GROUT SEAL PUMPED: ©" (IN. CONCRETE PEDESTAL BY DRILLER:U-l' ❑No S APPROX.DEPTH LOCKING CHESTER BOXISTOVE TOPE ' S PROPOSED CONSTRUCTIONMAILUNO METHOD; MUD ROTARY AIR ROTARY AUGER CABLE OTHER Com' U.-VU' ©"f-AP I HE9EBY CERTIFY THAT I HAVE PREPAREO THIS APPIJCATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY oR51NANCE9-STATE LAWS,ANO RULES AND REGULATIONS OF THE CAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;'I CERTIFY THAT IN THE PERFORMANCE OF TILE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY IN TIE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT t0 WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' T E PUC M e 4 HQ RM ADVANCE FOR ALL REQUIRED INi/►�ECTOkf Al'M")440-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED.BI ned x 1 'ICJ f 411f/- /f✓/� � - - --- Gam•_• D#ta- PLOT PLAN Ilkaw to Sod01 Sed. 'to 1. NAMES OF 8TREET6 OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4- LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED Z. OUTLINE OF THE PROPERLY,GIVING DIMEN814NS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTFM6. , e, 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. .. ,..E., ..: ...:., . :. ..... ..... ...._. ..,. - .. y� aa C` .. , ..� ........ .. .p..... ., .. ....,. :.. s�.N: 9 :.. : t DEPARTMENTUSE ONLY., App11aH1en Awpted By balm Grout Inapoellon By Dole U p 1naPoetlon By Date DeNmellnn Imp000don�By Dale Cam~mdN r �'V / LM A i Cc., ACCOUNTING ONLY: ARO# FAC# PE CODES FEE INTO AMOUNT REMITTED HEC ICAS14 RECEIVED BY DATE PERMITISERVICF REQUEST NUMBER INVOICE 412 190 D 6D Pub.Health Serv.-EnvirD,173(1/07)