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PLICATION F0I3 WEU/PUMP PERMI D/ V SANL�AQUIN COUNTY PUBLIC HEALTH SER%—/;ES ENVIRONMENTAL HEAJTH DIVISION I�jO 304 EAST WEBER AVENU TOCKTON, CA 95202 (2 468-3420 � � �G �NY, rJOR-REFUNABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �'`, � (Complete In TrtpRsote) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 ANDJ THE BTANDA 8 OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORE98/OR AIN# (g fg h�!/17 r��T'y 1� 1 K PARCEL SIZE/APNI s f OWNER'S NAME ADDRESS .Lt,J• J .J PHONE CONTRACTOR ADDRESS Co ,3 PHONE OUR CONTRACTOR I ADDRESS LIC#'F'P"+--C''+�PHONE _TYPE OF WELUPUMP; ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL I t-c O ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B ❑DESTRUCTION: INTENbED USF TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMESTWIPRIVATEGRAVEL PACK/812E TYPE OF CASINO/STEEL/PVC f DIA.OF WELL CASINO_ D ❑ PUBLIC/MUNICIPAL 9DRIVEN DEPTH OF GROUT SEAL SPECIFICATION ^ CTA R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E lJ ❑ MONITORING GROUT SEAL PUMPED: Yea ❑Nov, /�� CO/��1{CRETE PEDESTAL BY DRILLER:❑Yee ONO S APPROX.DEPTH LOCKING CHESTER SOWSTOVE PIPE' oca( `(v� S PROPOSED CONBTRUCTIOWDRILUNO METHOD: MUD ROTARY AIR ROTARY_AUGER CABLE V- ,1 OTHER 1 HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE GONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'8 SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 914ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN TIIE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MV CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPIECTIONS AT 12001400-342S. COMPLETE DRAWING LOWER AREA PROVI ED. /IA�I/LI 1 Signed X Title '"" Dau PLOT PLAN(Mew to Scale)Beale It to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUMMM THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF TNT PROPERTY,GIVING DtMENMNS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL 0YSTEMS. e. DIMENCIONED OVTLMF.O AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. 9TRUCTVR20,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. Ohl ... .... ............ ::..........:....:.... .. AppDEPARTMENT USE ONLY 40 Application Accepted By Date Grout IMpectten By Date Pump Impaction By Date Goetrta:tlen inspect IV Data Cemmonta• ACCOUNTING ONLY- AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE • Pub.Health Serv.-Enviro.173(1/97)