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+r r APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (109) 468.3420 PAYMENT NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED RECEIVED (CRmplo(s in Triplicate) �r, t3, APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY Fon A PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCnIRED,THIS APPLIW"TgL,IIE4 19-MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SEnVICEB,ENI If RONM�( '4 L ATH DIVISION. ' JOB ADDRESS/On APNjF ^D� r-•�(��JjUj �L 81ZFJAfyJI OWNER'S NAME C.-` C/�jJ/ AO ESR Z��—12� �L�dn�I�v ONE#14f-%,-7 CONTRACTOR Cr '� S rI SLD'Z p t 4L e ADDRESS Ip C364J5 Gyp 51 —C4LICI .Z.Z��pQ P{{ONE/g��o J 7 SUB CONTRACTOR OL / \QQ�/p(� ADDnFSS p}IO 7l _TYPE OF WELUPUMP; LAS NEW WELL ❑ nFM.ACEMENT WELL L7 MONIT GnINO WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS.CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 1 ,/ R VPE OF PI1MP1 13 Now 11Ropetr H.P. DEPT If PUMP SET FT. FIRST WATER LEVEL�� 0 ❑ OUT-or SEnVICE WELL ❑ GEOPHYSICAL WELL 1 ❑ SOIL BORING S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCIION SPECIFICATIONS ,p - A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION Z] DIA.OF CONOUCTOn CASINO O ❑ DOMESTIC/PRIVATE [J-G'AVEL PACK/SIZE 0-`02— TYPF.OF CASING/STFE DIA.OF WELL CASING L I 0 ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GnOUT SEAL � SPECIFICATIONeL>- N ❑ IIAA'RIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME '� ` E UMONITOnINO T GROUT SEAL PUMPED: ❑Y— LYNn CONCRETE PEDESTAL BY DRILLER:❑Vr Ne S APPROX.DEPTH- D LOCKING CHESTER BOX/STOVE PIPE 5 PROPOSED CONSTAUC TIO NRXBWNQ METHOD: MUD ROTARY Ain ROTARY AUGER_ CABLE OTHER I H"ERY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOnK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND "FOULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNEn On LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH T14I8 PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S AIRING OR BUR-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK ron,WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.' THE AP CANT MVST CALL H011Ra IN ADVANCE FOR ALL REQUIRED INSPECIlON6 AT 12061469-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. r 61grwA X_J� Tltle_� �aa AS �... Dete PLOT PLAN 10,ow to Salve)Seeie to 1. NAMES OF STREETS OR ROADS NEAREST TO On BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED I. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH O1nECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED rirTY FT. STRUCTUnEB,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PnOPEnTY On ADJOINING PROPERTY. :. .. ;. ... .... .... . : / DEPARTMENT VSE ONLY APPlioetlen AeaepleA By J'Q 1`,_N�U'l�� Do / 1 A— L,-0, � �� •/�I Groin Impoellon By D.I. P%—P Impeetlen By not. Doetrmtlon Irnpeallon fly not. Commdrte: ACCOUNTING ONLY; AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK /CASH RECEIVED SY DATE PEAMITIRETLICE REQUEST NUMBER INVOICE J i Pub.Health Serv.-Enviro.173(3/96)