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APPLICATION FOR WELLIPUMP PERMIT USAN JOAQUIN COUNTY PUBLIC HEALTH SERVIhf ENVIRONMENTAL HEALTH DIVISION RO, BOX 388,3"EAST WEBER AVENUE, STOCKTON. CA 9MI-388 (209) 469.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED lComplete In Trlpliette) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORESSIOR APNI �q C) 1 - V L N 1l�. CITE S4 O C K+0 A PARCEL SIZEIAPMS {� OWNFA't � Jn NAME e, lO _Ll l 64, G..?.. �aiin H-!{ul_R{�ADDRESS �D. _13t]x I/O.� PHONEeL,a4-Yk5 - 3Vzj CONTRACTOR E Ge hl L_. AODRESS/at-1 W. MAR(.1414/VElucr bbQZZ7PFIONE#M- 95k—QZby 57 CUB CONTRACTOR •+G C LICiatn [A q LJ7 F ADDRESS Z73 1 ucf_b_7 Z_b 1 7 PHONE A! _b5 Z-4555 INgfu4HO ilkspQgp -, TYPE OF WELLMUMP: NEW WELL ❑ REPLACEMENT WELL iK MONpIITORING WELL I M S ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CnObTILU9CON G 1 EPAQA ACFFi, AVf. ❑ VAPOR EXTRACTION WELL I J ©New❑Rppalt N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELLI ❑ SOIL BONNo g ❑DESTRUCTION: INTENDED Ust TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ WOU5TRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION it DIA.OF CONDUCTOR CASINO N p $Ra D '7 DOMESTICIPWVATS t36"W PACKISRE TYPE OF CASINOISTEEI.IPVCC V(� DIA.OF WELL CASING OI I! 11 b ❑ PUBLICIMUMCMAL ❑DRIVEN DEPTH OF GROUT SEAL J' 4Q S x�FfAC/L_ SPECIFICAMP4 fl ! O g q❑ IMGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY..Tki1m 1_ M£A20 GROUT BRAND NAME T p cA4 E IOL MONITORING GROUT SEAL PUMPED: [I Yes UNe CONCRETE PEDESTAL BY DRIMER:RY. [IN. S i APPROX.DEPTH_ Q LOCKING CHESTER SOXISTOVE PIPE Y4� S PROPOSED CONSTRUCTIONIDRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER k CABLE OTHER I HE9EBY CERTIFY THAT 1 IIAVE 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 JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIER THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT to ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN't 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,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1201 4GS-2422, COMPLETE DRAWING AT LOWER AREA PROVIDED, BynedxI —Tilts S4�1FF �Co10 151 Data DL13--5 PLOT PLAN ID,ow to Saelel Spate 'to 1. NAMES OF STREETS OR ROADS MEANIEBT TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 9. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. 1 DEPARTMENT USE ONLY IlMeeetfen AenMted By - bete MM a,oul k"PectIon BY Data Pump tnapetlon By Date OeaOmtlon k,apeetten By Date Cem.at ACCOUNTING ONLY: f FACT - ] PE CO�O'yEt FEE INTO AMOUNT REMITTEDCHECKIICASH RECEIVED■Y BATE PERMIT1iERVICE REQUEST NUMeB1 INVOICE V! Health Serv.-Enviro.173(3196)