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APPLICATION FOR WELUPUMP PERMIT USAN JOAQUIN COUNTY PUBLIC HEALTH SEAVI ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388,304 EAST WEBER AVENUE, STOCKTON, CA 95201 X88 (2091469-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER IEampl$t$In TTip11c$tal APPLICATION IS HERE BY MADE TO THE SAN JOAOWN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 ry�AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. 7� JOB ADDRESSOR APN/�^!3 SDu-h V4 RLA C'e II S+{e-t-____ CITY PARCEL Sf Z+LEI-A--PND 141�U''LCJ�2Aq OWNER'S NAME W��1 �NI 13LI Iji TGLf�r Gl tS ADDRESS D 13 4' _ i J ``�W Y7ri7NE I }� CONTRACTOR f T� I C. D($D E68A1weIS *Jft CSCli1gn UC, PHONE 13�U SUB CONTRACTOR��f 11 GA\1 Y �II�YY�Q -tA - -ADDRESS�r�.l E� SDTj S_ ._LK:N L�✓ O 1E.� PHON�I "_4S TYPE OF WEt.UVMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ M-NtroRING WELL R ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRO 88-CONNECT REPAIR CI VAPOR EXTRACTION WELL N J 13 Now 0 Repelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL E I•- SOIL BORING, ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INr)us-r tAL ❑OPEN go"OM VIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O CI DowartcR nivATE ❑GRAVEL PACX/812E TYPE OF CASINOISTEEUPVC DIA.OF WELL CASINO b ❑ PURLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION H ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E 0 MONITORING � ,^ 1 GROUT SEAL PUMPED: 11 Y. ❑YNa CONCRETE PEDESTAL BY DWLLER:❑Yw ❑Ne S APPROX. n DEPTH r• u Y{J_yr± LOCKING CHESTER BOX/HFOVE PIPE_ S PROPOSED CONSTRUCTIOMM MLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHERd i�ttA 114MRY CERTIFY THAT 114AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AOENT'S 810MATUM CERTIFIES THE FOLLOWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SMALL NDT EMPLOY SONG SUBJECT TO WORKMAN'$CoMPENMTION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB.CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: RTIFY THAT 1N T11 -RMA E OF T WORK FOR WHICH THIS PERMIT 16 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' A CANT MUST CA 2 OeNrO1 ALL REOVIRED INSPE+CTION`$AT`12�MI,Ib-i4+22../COMPLETEE O(RRAAVANG AT LOWER AREA I'ROVI ED. n Blcned X Title'IOv A V c- IT C, o { bete IR 7 PLOT PLAN IDrew to Basial Boele,. 4o 1. NAMES OF STREETS OR ROADS NEAREST T-OR SOUNDINO THE PROPEITIY. 4. LOCATION OF 14OUSE SEWAGE DISPOSAL SYSTEM on PROPOSED 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 S. LOCATION OF WELLS WrTHIN RADIUS OF ONE HUNDRED FIFTY FT. BTRUCTUREB,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, Q : OTPARTMENT USE ONLY APpllealton AoaaPW By r Gala Ar.e Grout Impaction BY Dale Pt p Impeatran By Dale Deatrtretlon Inspection By Dole G CammenU• �^G \ k G r� 5'7�Yst__ '1'D 5 tGlyv F✓1C_ �j�� W I ACCOUNTING ONLY: AID/ FAC,/ PE CODES FEE INFO AMOUNT REMITTED CHECKIICASH RECEIVED BY DATE PEr"TISERVICE REQUEST NUMB9L INVOICE Pub.Health Serv.-Enviro.173(3/96)