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APPLICATION FOR WELLIPUMP PERMIT USAN JOAQUIN COUNTY PUBLIC HEALTH SERVIewr ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON. CA 95201388 (209) 468.3420 NON-R{FUNRABTE PERMIT EXPIRES T YEAR FROM DATE ISSUED ICempletE In 711pReatal APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANnrOR INSTALL THE WORK DESCRIBED.TIIIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TTITtE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUKr�TY PUBLIC"HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRt8810R APNI 25`0 yPA�1-F 1,�/ Ay e Ayt- CIT11 -7J� ,t`q Q t,/ PARCEL SIZEIAPNE C OWNER'S NAMEy �T' ADDRESSn1 � 1� �. Arl�iron5 Ps"101- PHONE 0 ?1)Ci'�b7-Ip� COMPACTOR t ADDRESS)b_ 05 W, A'�,AJ?I-N tAn£31A ucI IO$p22 7 PHONE ICI ,5 Ina QZ b SUB CONTRACTOR}"{. ..,..__ ADDRES[ JI� F .IM},rA IOMA Ave."" L8Q't.2`! PHONE 111Y_ I -SI�J TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I I] OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CR098-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J 13m.❑Rap.tt H.P, DEPTH PUMP SET Fr, FIRST WATER LEVEL O (TYPE OF PUMPS ❑ OKrT-0E-SERVICE WELL ❑ aEOpF1YSICAL WELL R IV SOIL BORING S g ©DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ` A ❑ INDUSTRIAL 11OPEN BOTTOM DIA.OF WELL EXCAVATION___.J, �� ' DIA,OF CONDUCTOR CASINO-y D ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISI7E TYPE OF CASINOISTEELIPVC !JI 1ADFA.OF WELL CASINO tilA- D ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL�+CL SPECIFICATION 1 B ❑ IRRIOATION/AO 11 OTHER GROUT SEAL INSTALLED BY PI'PQ OROUT BRAND NAM IG J r MONITORING r GROUT SEAL PUMPED: ❑Yaa We CONCRETE PEDESTAL BY DRILLER: Yea ❑Ne S APPRO%,D[►TN LOCKING CHESTER BO%!lITOVE PIPE_ S PROPOSED CONSTRUCTION(DAIR ING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHEPA Ge lRpha.. 1 HE9ERY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND T14AT THE WOW(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,SLATE LAWS.AND RULES AND REGU AMNS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORXMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR RUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT Is ISSUED,1 SHALL EMPLOY PERSONS BUBJECT TO WORKMAN'S COMPENSATION t.AWt OF CALIFORNIA.-.SHE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL PIRGUI IED INSPECTIONS AT(K("61 449.5423. COMPLETE DRAWING AT LOWER AREA PROVIDED.) [� PLOT PLAN Resew to Seale!Boole 'to 1. NAMES OF BTREETB OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR P nOPOStD 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, SEE - 06, PjaN DEPARTMENT US£ONLY Applioetlen Aeeeplad BY 12• �j'`'f ONe L A<w Gout ImPoolbn By Dafa P1 p Infpeetlon By Data Deet—lion kopecllon By /� L c— Date CemmerMa: QL ��✓� '� 2 b v( � A�—,i a— —S ACCOUNTING ONLY: AIDS FACS PE CODES FEE INFO AMOUNT RET1+11TTE4 CHECKIICASII RECEIVED BY DATE PEM"TUSERVTCE REQUEST NUMSM INVOICE - b 2 Lz� I t Pub,Health Serv.-EnvirD.173(3196)