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"PPLICATION FOR WELUPUMP PERMI- SAN'k..dAQUIN COUNTY PUBLIC HEALTH SEh%,.,ES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)458-3420 NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED APPLICATION IS HERE BY MADE TO THE GAN JOAOUIN COUNTY FOq A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.Tllrs APPLICATION 16 MADE IN COMPLIANCE JOAQUIN COUNTY DEVELOPMENT (COMPlata In TFlplieata) LE,CHAPTER 0. 15.3 AND THE STANDARDS OF SAN JOAOUIH COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB AODRESSIOR APNI/, NCE WRIT SAN OWNER'S NAME �j�{,/ C� PARCEL @I7ElAPNf ADDRESS �S CONTRACTOR SNE R gg�5 j_v CONTRACTOR ADDRESSt k AM� �TYPE Ael ]Ej •[ OFLLlPI1MP, ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL r r3- ❑ INSTALLATION ❑WELL SYSTEM REPAIROTHER L{ ❑ CROSS-CONNECT REPAIR ❑ APOR EXTRACTION WELL r W1.7 ` New 11 R".1, POR DEPTH PUMP SET FT. {TYPE OF RlMPI FIABT WATER LEVELD ❑ OUT-Of-SERvICE WELL ❑ GEOPHYSICAL WELL r ❑ SOIL BDRNO ❑DESTRUCTION: INTENDED USE TYPE OF WELL CON6TRUG7ION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASING A ❑ oompaTICIPRIVATE ❑GRAVEL PACK1817E TYPE OF CASINGIBTEEDIA.OF WELL CASING O __ 6'[ �Y A 11 PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL , SPECIFICATION S ❑ BTRtomio IAo ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORINGGROUT SEAL PUMPED: 11Ve■ [I No CONCRETE PEDESTAL BY DRILLER:❑Yoa ❑Ne s APPROX.DEPTH , LOCKING CHESTER BOXAYTOVE PIPEs PROPOSED CONSTRUCTIONIDMLUNO METHOD: MUD ROTAR AIR ROTARY AUGER 7,--CABLF OTHER I HE9EBY CERTIFY THAT 1 HAVE PREPARED TH1B APPLICATION AND THAT THE WOR(WILL 8E DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANTE ILEOULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AOENT'B SIGNATURE CERTIFIES THE FOLLOWING;-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICN THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'@ HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMrr 16 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORWAAN'a COMPENSATION LAWS Of CALIFORNIA.' THE&PPLICANT MUST CALL24HOURS IN ADVANCE FOR ALL REOUIRIID INSP ECT IONS AT 1"914404422. COMPLETE DRAWING AT LOWER AREA PROVIDED.q� Blared X Yi{L.{ Title ._. Dae / 1, i PLOT PLAN 10row to Soolel Scale 'to 1. NAMES OF @TAEETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 4. LOCATION OF HOUBE SEWAGE DISPOSAL SYSTEM OR PAOPO@ED 2, OUTLINE OF THE PROPERTY,GIVING DIMEN@IONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, S. 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, a .. V . . ; fir, .�.r�cs,c•Ct PAYMENT RF_CE!1/1F 'w 'JUL 7 1998 �, 5AN:J0A(,}U11v.GCsUNTI' ES ENVIRONMENTAL HEALTHID1 SI0N l DEPARTMENT USE ONLY f /� IWP11aalon Aeeapled By Dole 7/ �y L- A••e7 - Groin kwpeetlon BY Dae Pump In■peetlen BY Dote OMlna:llen Inapeelfon BY ��_y7i`i:. .�1.�, �,.,- r/ P i�,,..r..0-!� _ Date ACCOUNTING ONLY: AID! FACT PE CODES FEEINFO AMOUNT REMITTED HECKr ASH RECEIVED EY DATE PERMITISEAVICE REQUEST NLIMBtR INVOICE '1 2 016 / Pub.Health Serv.-Enviro.173(1197)