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3 APPLICATION FOR WELLIPUMP PERMITR AN JOAQUIN COUNTY PUBLIC HEALTH SERYL ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988, 304 EAST WEBER AVENUE, STOCKTON. CA 95201388 (209) 468-3420- NOR-REFUNDABLE 68-3420NON-REFUNDABLE PERNIK APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY OEVELOPMENT TTTLE,ICHAPTER 8.1 1 15.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DRASION. a' JOB ADORESSIOR APNf_I 1 Q n, ��,-I�i{ �'[r�-�-T; /^i-vtx it T!Cy �`�f�, /P{�A�RRCEL�BVIWAPN/ OWNER'8 NAME /'l� lW t ADDR£SBy „ ( �I jf ICV`4/r��,_ PNONE P { it " CONTRACTOR ZUO I tPu� `s jy1.YUSC,(4) 9D)o sta- PHONE S 'JJlS` + SUBCONTRACTOR r _ - ..9� 1-}0 we. tKd Qa rte neC.Cl4 9y�.5 3 LICA rHONE,'c"513 $Zx] TYPE OF WE PVMP, ❑ NEW WELL ❑ REPLACEMENT WELL 0.MONITORING WELL, -� 13 OTHER f ❑ BJSTALLATIO,N ❑ WELL SYSTEM REPAIR ❑ CROSeCONNECT REPAIR ❑ VAPOR EXTRACTION WELL, J ❑N..❑Ropd( H.P. DEPTH PUMP Off FT.- FIRST (TYPE OF PUMWATER LEVEL O P► 0 OUT-OF-BERVICE WELL• ❑ GEOPHYSICAL WELL P X SOIL AORINO � l..l DESTRU/CTIDN: � �- f. _...... �.._._ �t--..�-- --'"'^`•�•. _�... � '.� .---- - . . INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS - ,A I iy ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION GIA.OF CONDUCTOR CASINO Q ❑ DOMESTIC/PRIVATE ❑GRAVELPACKISIZE TYPE OF CASINGISTEEUPVCDIA.OF WELL CASINO Q ❑ PUBM MUNICIPILL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION - p ❑ IRRIGATION/AO ❑OTHER - GROUT SEAL INSTALLED BY ORDUT BRAND NAME f 0MON1TdRING �J }--- GROUT SEAL PUMPED: ❑Yw ❑No CONCRETE PEDESTAL SY DRILLER:Q Ym ❑Ne S APPROX.DEPTH �`^-J 4 - T w 'LOCKING CHESTER BOXMTOVE PIPE yy�p S PROPOSED CONSTRUCTION/D"LLNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER *��+n-- I HEMIEBY CERTIFY THAT I HAVE PREPARED THIS APPUJCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S 01ONATURK CERRIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUSCONTRACTRNG SIGNATURE CERTIFIES THE FOLLOWI '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORC FOR WHICH THIS PERMIT!S ISSUED,I SHALL EMPUAY PERSONS SUBJECT TO WORIOYIAN'S COMPENSATION LAWS:OF CALIFORNITiiE AAPJCANT�RMUST CALL 21 MOISU IN ADVANCE FOR ALL REQUSUEn R/iPEICTRDNS At i70SI 4Si.742f._COMPETE DRAWING AT LOWER AREA PROVIDED. ��- PLOT PLAN IDrrw to 8aalol SeoN � 'ee -. - _ 1. NAMES OF STREETS OR ROADS NEAREST TO DA BOUNDING 7HE PROPERTY. �. LOCATION 4F RNOUBE BEWAfif DFSPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE Fi00PERTY,GR1AN0 DIMfkS10:i8 AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL'8Y8TEM0. . 3. DIMENSIONED OUTLMF.S AND LOCATION OF ALL EXISTING AND PROPOSED .v - � - � 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.r STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. t 'li �.w• w-.r err• 'w' K Y .. .. ..p ,o-N ... ............. . .. ................................ .............................. ........... ....... DEPARTMENT USE ONLY AIWIootlen Aoeopted By Date Aroo Grein Impaction By Olde P—P Impoo0on By data Danrution Impootlon By Dais , j Comments: ACCOUNTING ONLY: ALIO, FAC, PE CODES FEE INFO AMOUNT REMITTED CHE'CK,UCASH RECEIVED SY DATE PEWJITISERVICE REQUEST NUSN09I INVOICE