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f t APPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388,904 EAST WEBER AVENUE, STOCKTONt CA 95201388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Comple(s IN TFlplieBlII) APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.TI{IS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOP^^MEW TITLE,CHAPTER 9.1 115.3 AND THE STANDARDS OF BALI JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH MVl810N. of JOB ADDRESS/OR APNI q r)r 2 [[PgL4:1111 c.��..; `,, CITY SID O� ^-� PARCEL SIZFJARII OWNER'S NAME.//�� -„C GIO A .I P Lk'�'LMOtt �ADORES@ ! PIbNE I Y 2) CONT Mc7oR_HAyU nCFnII LSenn n./�r n5„ ADDRESS 5 W. L,f}^ ,y2�'�AI b$O�Z-7 PHONE\4�,74rJ `Z SUBCONTRVICTOR 4. f +cJ f) ADDRESS-�(+nnf I��jK r7[ �7' LICsQ 617 PHONEIy 5a•�55g i�nnm��4.L7�tyt_1'}O La R12 TYPE OF WELUPUMP, ® NEW WELL ❑ REPLACEMENT WELL ❑ MOWTORINO WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRO98-CONNECT REPAIR VAPOR EXTRACTION WELL/V!U'r vtv-d1' J (TYPE OF FV MPI ElNow L3Rape, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ colt BOFVtio g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CON*TR1IC7fON SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION _ DfA.OF CONDUCTOR CASING ~/_ } DOMESTICIPR IVATE 13 DF2 -�./t p ❑ 5 D TYPE OF CASINGISTEEUPVC L .-- VIA.OF WELL CASINO 10 C1p PU13UCIUUMCIPAL ❑DRIVEN L DEPTH OF GROUT SEAL it ;�& )O''�a Sv IPfAC&. SPECIFK:ATIOTI St NQ P0 9 g �❑q I RIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY JA EM;I M t{Ma P GROUT BRAND NAME PO 4i•10 Ac� _IY Q E IC E Rp L40MTOMNO GROUT REAL PUMPFD: ElY- ®Ne CONCRETE PEDESTAL BY DRILLER:(l Yr.[]No S PT APPROX.DEH- -22a FEF.Ir , G S G LOCKING CHESTER BOX/STOVE PIP'E_YC!5_ S PROPOSED CONETRUCTIONIORILUNO METHOD: MUD ROTARY AIR ROTARY AUGER---x CABLE OTHER I HE9EBY CERTIFY THAT I NAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH @AN 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 WOR(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR-8 HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING; 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT 18 ISSUED.I @HALL EMPLOY PERSONS SUBJECT TO WORIOAAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL PlIQUIREb INSPECTION4 AT 12"1 4SS1*422. COMPLETE DRAVANG AT LOWER AREA PROVIDED. @iSnad X Tnla STA r—r— O `7 Dqa PLOT PLAN lbnwv to 8eafal Sca,a •to 1, NAMES OF STREET@ OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PnoPOSED 2. OUTLINE OF THE PROPERTY,OIVM DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OVTUINF.B AND LOCATION OF ALL EXISTING AND PnOPOSEO E. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLVt RNO COVEREb AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY On ADJOINING PROPERTY, SEC pfoF�► ""CH 1"7 AaavNpve--► :..... . ... . ............ :......:...................:... ............ DEPARTMENT USE ONLY (/^ Applea(Ion Atreaptod BY Data-L./ 14.. Met”knpectlen By Date Pomp Inapactlen By Data beatnteeen impaction By beta Commenta:— � �_�f a Y !�Q• I • t�L..�+'1 4 1/VeLLS T. ACCOUNTING ONLY: AID/ FACT PE CODES FEEINFO AMOUNT REMITIED CHECKIIGASH RECEIVED BY DATE PUM,TISERVICE REOUEST NUMBER INVOICE a �� • 3• � a Pub.Health Serv.-En%4ro.173(3196)