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.F APPLICATION FOR WELUPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICampwtE hi Tr1plklts) APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 11 @-I 11 AND THE STANOARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERM VICES,ENVIRONMENTAL HEALTH D91ON. Joe ADDRESMR APNI_ ((!_,4jf.G , .L.�JL�/J�r � .�7aP[.L�+ CITY/ �jL.O PARCEL StZE/APN/ x OWNER'S NAME ADDRESS yI ADDRESS /UL.QCtT PHONE 924-aY3�/ COHTMCTOR " , ADDRESS_ J.LA. M �"rpy -'(Ac-LIC/ `n PHONE!ka-,-ZL I—t,+L/� SVS CONTRACTOR�,I J•H,�I�JGJ(� ADDIESS/41 'X` 912, JP, 4 [�LICPHONE N7- TYPE OF WELLMUMM ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL s ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR Q VAPOR EXTRACTION WELL I J ❑New❑RepW H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O RYPE Of PUMPI ❑ OUT OF-SERVICE WELL ❑ GEOPHYSICAL WELL/ AL-11.BORING g ❑DESTRUCTION- INTENDED-USE ESTRUCTION:INTENDEDUSE TYPE OF WEILL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKI8IZE TYPE OF CASMOISTEELIPVC DIA.OF WELL CA51NO D ❑ PUBLIC/MUNICtPAL ❑oNVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ tMOATION NAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME F ❑ MONITORING y GROUT SEAL PUMPED: ❑Yew [IN. CONCRETE PEDESTAL SY DPJLLER;❑Yr [IN. S AP X.DEPTH 6§Lt ' LOCKING CHESTER SOXMTOVE PIPE S PROPOSED CONSTRUCTIONIDMLLING METHOD'. MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE9EBY CERTIFY THAT 1 HAVE 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 JOAGUIN COUNTY. HOME OWNER OR LICENSED AGENT'S BIONATURIE CERTSIES THE FOLLOWING:'I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1614ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMF4MSATION LAWS OF CALIFORNIA.' Tjp AFPUCANT MUST CALL M HOURS IN ADVANCE FON ALL REOUI RED INSFECTIONS AT 120.1 4q-1422. COMPLETE DRAWING AT LOWER AREA PROVIDED, Slpnod X Title Y 149- _--. Date T PLOT PLAN gkow to Seryl Scale 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE 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 OUTLINED AND LOCATION OF ALL EXISTING AND PROPOBED E. LOCATION OF WELLS WITHIN PAWS OF ONE HUNDRED FIFTY FT. BTRIICTVREB.SNCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING WIOPERTY. DE►MTMENT VS!ONLY Avpllortlon AOVW d Sy Date I Ares Oreu1 lmpeetten By' ' ' Oste r (214 Pc P k»geatlen By ONe O"Iftntlen lmpoctlon a bete Cemmer.tr: . ACCOUNTING ONLY: AID/ FACN? PE CODES FEE INFO AMOUNT"EMITTED CHECKIICAEH RECEIVED SY DA 7 PERMITISERIACE REQUEST NUMBETI INVOICE I .3 PUD Health Serv.-EnVIrO.173(1/97)