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-�� - - -APPLICATION FOR WELLiPUMP PERMIT {, PAYMENT I I SAN JOAQUIN COUNTY PUBLIC HEALTH SERL l,, + RECEIVED ~ ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388.304 EAST WEBER AVENUE►STOCKTON� CA 9M`I' AN JAY 0 1906 TY (209) 488.3420 PUBLIC HEALTH eckVU;Es NON REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH aiV15.10 i ICampin TTipiiastr) AN AND THE STANDARDS OF SANTJOAQUINAND/OR COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. L APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDlOR INSTALL THE WOW DESCRIBED.THIS APPLIGATION 16 MADE IN COMPLIANCE WITH S JOAQUIN COUNTY DEVELOPMENT TITLE,CHAFTE 9-t 5• PARCEL SIZE/APNI . 2t CITY JOB ADDRESS/OR APN/ ` �� PHONE 1 ADDRESS Z o2 OWNER'S NAME Lr-uC�—PHONE R��L�+-k` -1 ` ADDRESS 5 CONTRACTOR `(J G LIC/ PHONE r �� 0 ADDRESS BUB CONTRACTOR 1 II MONITORING WELL n ng 1 '�W 3 ❑ OTHER ' t TYPE OF WELLIPUMP: .NEW WELL ❑ REPLACEMENT WELL J ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 2-�,�_ ❑ INST/LLIATION DWELL SYSTEM REPAIR O � DEPTH PUMP BET FT. FIRST WATER LEVEL ❑New❑Repelr H.P. ��qq (TYPE OF PUMP) - ❑ OEOpHYSICAL WEIi/ Cc SOIL BORIN 8 ` ❑ OUT-0F-SERVICE WELL l ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION /! DIA.OF CONDUCTOR CASING D t ❑ DOMESTICIPRIVATE RAVEL PACKISIZE i TYPE OF CASINGMTEE DIA.OF WELL CA61NO -r� D ❑ PUSUClMUNICIPAL DRIVEN DEPTH OF GROUT SEAL L r S SPECIFICATION � 5c—i¢�V I Q R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY, X1 Pr GROUT BRAND NAME f t' e E 4 §.MONITORING f / GROUT SEAL PUMPED: 5EYee ❑No CONCRETE PEDESTAL BY DRILLER:,RYe. ON. S. APPROX,DEPTH �� T[l / LOCKING CHESTER BOXWTOVE RPE S PROPOSED.CONSTRUCT10N1DRILIINO METHOD: MUD ROTARY AIR ROTARY AUGER��CABLE OTHER I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND 4 1 REGULATIONS 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 PERMrt IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING; 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERBONS SUBJECT TO WORKMAN S COMPENSATION LAWS OF CALIFORNIA.' T �APFUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOWRED INSPECTIONS AT 120014004423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slarxd X i]LI- t - _ Title r�p f��5 ' Det. �.J 0-9 PLOT PLAN IDrow to Some)Serle 'to I, 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,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 5. 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. ........ . .. - - ..:.... .:.....i .- .. .- .. .. .. .. .. .. :. ..... g'spt7.'LA cA YS�U� ;.. .." L1'i't�'QAC1titC A .. - ..,. _ 2 . 524 l .. .. .. . ......................:..._;-.-....:...............:....... ...._[. - - i 1ALLEY A4Ki1'tC L ` - F. vs . N ' O T, .. .. .. -- .....:.... y.... --.-........ - .. .... �n mel 4' •�t�Y311 � i. . n z` : .....:.-.... ..... anx£n 1 .. ...;_...i.....:. .... .. 02 PACS .. . i ..:.. .:.............:.......;.... -.. .. .. 24 ..,. ..' lG Av6NUB I r ,......:......:.... .: .....;..,.... ----- .. .. ., CAST:•. . i r . ..:, ... -. Lfi�OE�xn ecurc wcnee N I .... •�mew�ar�� .. ..-.-- i.. - dcreE ced I 1 - .. (p _ CAuSITE PLAN aN f 2,02 AVENUE . STOCKTON.00AIIFORNIA 2 .. . eo�.wron�enta ' rnxev.e a-<-.-e.n w x+vr�a .....xn: ae-n.x oenn e i _ ............. ... ..-.................. �• J DEPARTMENT USE ONLY Applloetlon Accepted By Dote Arao 3 Great lnapectten By Dote Pump Impectlen By • - bate Deotruetlon Impeotlen By - ,� bete i Comments: CJy I`+�I� f ACCOUNTING ONLY; AID# FACE fJ 1 PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE I ^ �� PERN11T15FRVICE REQUEST NUMBER ',INVOICE `