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APPLICATION FOR WELVPUMP PERM'— S* OAOUIN COUNTY PUBLIC HEALTH ICES ENVIRONMENTAL HEALTH DIVISIO 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 46$-3420 00 TION REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Camplats In MpDaals) APPLICATION 49 I4ERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED THIS APPLICATION IS MADE IN COMPLIANCE WriH SAN JOAOUtN COUNTY DEVELOPMENT/TI TLE,CHAPTER �9^1 1 15 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �/ � G�"� ~ / t \' J^ CITY �� C A f, II—) PARCEL STZElAPN1 roAmsJOB ADDREssR Ai CA 7 ! „ OWNER S NAME �'�N 5 1 _, ;4,� �C L "F ADOREsa Y I 1?r_`t V S ! ., ',.Y � ( y(� t/ I. r1y - .�...��(��_ �. V ! G PHONE tC Y� CONTRACTOR t`'IL1. 3 J. �_-- Cry _� r rr c-toe, t I �nl ADDRESS YY�5 rL sti �f } �v �) Ltc• `�_)(_<<7PHONE. RUB CONTRACTOR AGGRESS UCX PHONES TPEOF WNEW WELL ❑ REPLACEMENT WILL MONrTOf4NO WELL R 13 OTHER A �❑INSTALLATION 13 WELL SYSTEM REPAIR f❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 1 J ❑New❑Repelr H P DEPTH PUMP SET FT FIRST WATER (TYPE OF PUMP$ ❑ OVT-OF SERVICE WELL ❑ GEOPHYSICAL WELL 1 ❑ Som SORING 8 ❑DESTRUCTION INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ,l Cl INDUSTRIAL ❑OPEN BOTTOM DIA OF WELL EXCAVATION__- _ DIA OF CONDUCTOR CASINO �>' p Cl DOMESTICMMVATE /T GRAVEL PACKU64ZE TYPE OF CASINOISTEEl1PVC 1. DIA OF WELL CASINO 2 .iLO D Cl PURUCIMUNICIPAL ❑omvEN DEPTH OF GROUT SEAL I r— e 'I G _ 1' �tSPECIFICATION .X-d+ r' v7' R ❑ IRIBGATtONUAG ❑ EAL OTHER GROUT SINSTALLED BY 1 M�.n 1 L /''!.'/( GROUT BRAND NAME -P l Lr1r.�.� E `6MONITOMNO GROUT SEAL PUMPED yfJ Vw ❑Ne CONCRETE PEDESTAL By GRILLER,fy2 V— ❑Na S APPROX DEPTH COMING CHEBTER SOXISTOW PIPE Lr kX, I.+ LLkI PROPOSED CONSTRUCTIONWRILIJNG METHOD MUD ROTARY AIR ROTARY AUGERCABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIN APPLICATION AND THAT THE WOiK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES STATE LAWS AND RULES AND REOULATIONS OF THE SAN JOAO"COUNTY HOME OWNER OR LICENSED AGENT S SIGNATURE CERTIFIES THE FOLLOWING I CERTIFY THAT IN THE PERFORMANCE OF THE wow FOR WHICH , THIS PERMIT 18 tSNUEO 1814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR S HIRING OR mUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING '1 CERTIFY THAT IN TITS PERFORMANCE OF THE WORK FOR WHICH THIN PERMIT 18 ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORIGNAN S COMPENaATION LAWS OF �! S O T2ON1 4b�t2s COMPLETE DRAWING AT LOWER AREA PROVIDED ��RNM' THE APPLICANT MUST CAL!M$rouR.s sM ADNANC!FOR ALL RlQURED IMS/4CTTONS ATF ? `JG - �� _�l. GV�/1 L.r1�L---- A I ') r �j `` / One J �. " PLOT MAN Wre Ie Beelel Saab •4e 1 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 GfVTNG MMWMON13 AND NORTH DIRECTION EXPANSION OF SEWAGE DISPOSAL SYSTEMS ? DIMENSIONED OUTUNFN AND LOCATION OF ALL EXISTING AND PROPOSED S LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT STRUCTURES INCLUDING COVERED AREAS SUCH AS PATIOS,DFSVEWAYS AND WALKS ON THE PROPERTY OR ADJOINING PROPERTY tl1T USE ONLY Apa"atbn ACG"Ied by h (),out 1r»penlen By , Dne 4-Nr++v In.peeUen BY ONe Dale Den'uatlen lmpeel BT CemmerMe ACCOUNTING ONLY AIDS FACa PE CODES FEE INFO AMOUNT KNOTTED CHEC"ICASH RECfhtM BY DAT! f+431 OTNIU VICIE REQUEST NUMBER INVOICE 0 3-Z (rte SG' 17- Dub Health Sery Envlro 173(1197)