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APPLICATIbN FOR WELEIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERV ES ENVIRONMENTAL HEALTH DIVISION ORIGINAL�L,P.O. BOX 388, %x EAST WEBERAVENUE, STOCKTON, CA g5201�88 (LO9488.1420 _ RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUER ICOMPt.n in'TrIPReetfl APPLICATION IB HERE BY MADE TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY D£VELOPMENTT TITLE,CHAPTER 9-111115.3 AN THE STANDARDS OF SAN JOAOUIN COUNTY•.1�PpU,BIJC//HEALTIt SERVICER,ENVIRONMENTAL HEALTH DIVISION, JOB ADQRE88roR APMf goouk 6�( ` CITY \ 'Jlrl PARC L ZFJAPNOAt OWNER'S NAME_ S• i f� ADDRESS Q f �61�2— PHONE .4 {'--�� "l-I/gnCC fCONTRACTOR rpt• AbDREB$ 1 `I �"'�"�"' LICIT CTSUB CONTRACTORJ PHOf ADDRESS Z31cSlA1 R-iLtl7CN_CQ-71 {ONE/ 146 S 1 I TYPE OF�LL/Pl1MP• ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR } CROSS-CONNECT REPAIR ❑ VApOR EXTRACTION WELL f ❑New❑Repair H.P. DEPTH PUMP SET FT. J.. (TYPE OF PUMP] FIRST WATER LEVEL, _ I 0 . ❑ OUT-OFSERVICE WELL ❑ GEOPIIYSICAL WELL# ❑ BOIL BORING r 3 S ❑QESTRUCTIDN: 1I1'-N��TENDED USE TYPE OF WELL CONSTRUCTION SFICATIONS PECI11 � LJ INDUSTRIAL LlOPEN BOTTOM VIA.OF WELL EXCAVATION ti\�Qt.V� DIA.OF CONDUCTOR CA8ngG A , ' ❑ DOMESTIC/PWVATE ❑GRAVEL PACKMIZE TYPE OF CASINO/STEEIJpVC 't/ A /y DIA.OF WELL CASING ry ❑ PVBUClMtINICIPhL.��_❑_QISIVEN .DEI'TN UF_GROUT_SEALx:., y..0-- - 3 IIII----''''�� - - —•.....w�:.•c, �... - _- �SFEC.1FtCA7tON,.i R .. IRRIOAT ION/AG ❑OTHER GROUT SEAL INSTALLED BY Y'l C.�� I- GnOUT BRAND NAME �. LQ�1'Q E MOMTORING 1 GROUT SEAL PUMPED: ❑Yea ❑Ne CONCRETE PEDESTAL BY DRILLER;1Yw []me S APPROX.DEPTH 15 — LOCKING CHESTER BOXl870VE PIPE -. {{ A ,S PROPOSED CONE7RVCTIONIbRILLING METHOD; MUD ROTARY AIR ROTARY AUGER +CABLE OTHER W -Lj�� I u E I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH CAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULE$AND REGULATIONS OF THE BAN JOAOUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOFI(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL Not EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,' CONTRACTOR'S HIRIHO OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE Or THE WORK FOR WHICH THIS PERMIT IS IBSUED,I SHALL EMPLOY PERSONS SUBJECT t0 WORKMAN'S COMPENSATIC CALIFORNIA.' T E APP CA MT CAtl 2A HOURS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS AT I2oo1 4$84421. COMPLETE bttR33AWING At LOWER AREA PROVIDELAWS OF[r .�'+ �yN Blpned X r ^ �-! �� c-I�� • TliTitle Date PLOT PLAN(Draw.te Seelal ROals 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCA7KIN OF"OUSE SEWAGE 0I8P08ALlBVBTEM OR PROPOSED2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3, UIMENStONED OUTLINEB AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WrrHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY, . j DEPARTMENT UBE ONLY APpllaatlen Acoepted By 6reul lrrapeetlen BY m,,.,.......- .•` '.'-.� •,Se, :.a- ..r�.s.�.r�....r.a�+ _,,,,, bale bate Ptrnp Inapectlen IN / Oeatnrcllen Inapse BY - _ - bate Cemmnrla: a +r Data I ..jy61 . p ACCOUNTING ONLY: AtbN " FAC# r PE CODES FEE 1Nr0 AMOUNT REMITTED C{IECKNlCASH - - ' _ RECflVEO BY DATE PBIMITlSERVICE REOUE4t NUMB9i INVOI[Ezt ' 2-1 tos. Pub.Heafth Serv.-Envlro.173(3198)