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APKICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 38$, 304 EAST WEBER AVENUE, STOCKTON. CA 95201-M (209) 468 3420 isNON REFUNDABLE PERMIT EXPIRES i YEAR FROM GATE ISSUED (C-mpinh In Mplielt/l APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANUMR INSTALL THE WORK DESCRIBED THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE CHAPTER 9 111 S 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION JOS ADDWSSIDR APN. �`1"'1- �`X`r�r 1 �'�-f#wC�,1 r� pyw1 Cir c k PARCEL pS1zE/APH. D� OWNERS NAME "ry) ] T ADDRESS �— +�i� CIL 1 1'1 I �vl LLY�I.J� i�. (�� Z IO CONTRACTOR 1 1 �'S 4 y t 1� � 1 C�.OI - L 0 PHONE -��-r n AtKw9S ��`rirh„,�'�L r!Z uCff 121 � ��[ 111: `T��f RUB CONTRACTOR i AOONRESB UCl PHONE/ TY OF WELJJPUMP• HEW WELL ❑ REPLACEMENT WELL MONITORINO WELL 1 _ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I (TYPE OF PUMP) ©H.❑Ri w, H P DEPTH PUMP SET FT FIRST WATER LEVEL p ❑ OUT-OT SERVICE WELL ❑ GEOPHYSICAL WELL 1 ❑ SOIL BORING g ❑DESTRUCTION 4 INTENDED ULE TYPE OF WELL CONSTRUCTION SPECIFICATIONS JJ AA A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA OF WELL EXCAVATION �-+I n A r`1 Z-F!^� DIA OF CONDUCTOR CASINO VJ ❑ DOMEs ncmRIVAtE ®GRAVEL.PACK113IZE TYPE OF CAStNG19TcttmvC ' k'1? DFA OF WELL CASING I I t,,i CT-C p p ❑ PUBUC/MUNICIPAL ❑DRIVEN OfPTH OF GROUT SEAL 'Z SPECIFICATION rt ❑ IRRIOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY D GROUT BRAND NAME011 1 A r^�_{ (YyI P.� - E MONITORING A GROUT SFAL PUMPED M Y.. (IN. CONCRETE PEDESTAL BV DRILLER.❑Y. ❑Ne 5 APPROX DEPTH 0 LOCKING CHESTER BOX/$TpVE PIPE ✓ $ PROPOSED CONSTRUCTIONIVAILLING METHOD MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY CHAT I HAVE PREPARED THIN APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE 1MTN SAN JOApU1N COUNTY ORDINANCES STATE LAWS AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY HOME OWNER OR LICENSED AGENT B SIGNATURE CERTIFIES THE FOLLOWING I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TS SWAO�L. PERMIT IS ISSUED I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN N COMPENSATION LAWS OF CALIFORNIA- CONTRACTOR S HIRING OR SU"ONTRACTINOIG SIGNATURE CERTIFIES FOLLOWING I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TMS PERMIT IS ISSUED I SHALL EMPLOY PERSONS SUBJECT TD WORKMAN S COMPENSATION LAWS OF FORNIA' 7HE T M CALL 24 HOURS IN ADVANCE FOR ALL RE9URED INSPECTIONS AT 12011 4//.1422 COMPLETE ORANRNO AT LOWER AREA PROVIDED Storied X A TIM. A7'1I•I t� PLOT PLAN ID.aw to s..w s.N. L_-to- 1 NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY 4 LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2 OUTLINE OF THE PROPERTY OMNO DIMENSIONS AND NORTH DIRECTION EXPANSION OF SEWAGE DISPOSAL SYSTEMS 3 DIMENSIONED OVTUNFS AND LOCATION Of ALL EXISTING AND PROPOSED S LOCATION OF WELL$WITHIN RAOMS OF ONE HUNDRED FIFTY Ft STRUCTURES INCLUDING COVERED AREAS SUCH A8 PATIOS DRIVEWAYS AND WALKS ON THE PROPERTY OR ADJOINING PROPERTY Rostov ii-a- r La-,oZlIerofc,54 WnrI-W146 in e", s DFDARTMENT USQ ONLY Applk.tlen A.eapted By / / Dot. Qr.u1 Ir»peetlen BY Date Plrnp Inepeetren By PH• b.etni.,Mn Irwn tbn B Date Cerement. G(f ACCOUNTING ONLY AIDS r� FACS P!CODE. FEE INTO AMOUNT REMITTED CHECILiftASH RECEIVED NY DATE POW TINVIVICE REQUEST NUMBER INVOICE cc776 AX- 11 aCZ Pub Health Sery -EnvlrO 173(31%)