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PLICATION FOR WELUPUMP PERMI- SANWAQUIN COUNTY PUBLIC HEALTH SEI .;ES RA.lrMENT ENVIRONMENTAL HEALTH DIVISION It i?;F0E9 v P=0 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 AUG 12 1997 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) SAN JOAQUIN COUNTY APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCRIBED.THISRI`R1d%IWftftTIMA*FW LIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH 6ERVICE6'ER I �ENi'/FlAirx 6��>4K'�i,CiN JOB ADDRESS/OR APN# /-459(2)L2✓ NC /-/"I _ �F� CIT.Y[1, P'AR.C�ELV'612E-/APN/ OWNER'S NAME ' - [tj ADDRESS /rr(.jam 7(�'lI [�j �✓7'k/-�!y(L�'PIION / L-r/_] '��77L_ CONTRACTOR h Cif' �y!/LL:C-1 ADDRESS VI'.jJ3 11,1r9r .L/] r� UCI1fiT ��✓ PHONE# ^ ADDRESS sok SUR CONTRACTOR del C UC/ PfiONE TYPE Or WELUPUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑New❑Rep.I1 H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O IT VPE OF PUMP( ^/ ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# []/SOIL BORING g ❑OFSTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A, A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 2�r DIA.OF CONDUCTOR CASING ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC C J, ^ DIA.OF WELL CASINO p ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL C�I'J/-y�J SPECIFICATION 1,, R ❑ InRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY�'I L( GROUT BRAND NAME LY=J _.yL2 E ❑ MONITORING GROUT SEAL PUMPED: ❑Yee WN. CONCRETE PEDESTAL BY DRILLER:❑Yw ❑No S APPROX.DEPTH l;7 LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRLICTTOWDWLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER �� I HERERY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND nEGLILATIONS OF TNF SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WTIICH 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: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'/COMPENSATION LAWS OF CAI IFORNIA.' T1HE�A/►J,�11{'C!J�/1(�lCJf�MV1T CALL 21 HO! 4/[/IJ ADVANCE FOR ALL REQUIRED INS�PEECC71ON/e AT 12091469-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. 7 Slpned X W IL'y"�CY��1 J � I��CJ�� Tltls Cinz i 0-t PLOT PLAN ID-to So lel Seel. 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 1. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROP06ED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTUNE8 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNOnED FIFTY FT. STRUCTUnES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. _.. ... 1 /,�•p.�n,(///7 DEPARTMENT USE ONLY Applle.11..A...otqed BY. ^�r�Cv""" — `- Det• 1 1 Ar Grmd Irxp-0—By Det. Pump Impaction BY Dole 0-t-11—Impectlon By Cemmdrle:�� ,i W• /�+�� ,(^� �?'� (M �-C,T D �M'tj•L ACCOUNTING ONLY; AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#ICABH RECEIVED BY DATE PER/M�ITISERVICE REOUEST NUMBER INVOICE 9. O � lir 031 / V Pub.Health Serv.-Enviro.173(1/97)