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APPLICATION FOR WELLIPUMP PERMIT ;AN JOAQUIN COUNTY PUBLIC HEALTH SERVIG, ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 469.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cemplet•In Triplic$tel APPLICATION IS HERE BY MAOE TO THE SAN JOAOUIN COUNTY Fon A PERMIT TO CONSTRUCT AND/OR INSTAtt THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WDH SAN JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER B-1 1 16.3 AND TIRE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOA AODRE69/OR APN/ J_ W S. �1 w y 33 R, ,F_oc � c clr�Q Ver na\i s , C1, PARCEL SIZE/APN# � OWNER'S NAME S+2r11 f7c, 1 JeC V I C.P� ADDRESS QD poY Il�ja F�GS�YO� CPQ 13�I1.S RIONE f /�g�—� 3 G Slo CONTRACTOR GCOSa�Y1�eC Cov,[1.1iaLn�S i ,,� W+ • 00 _ /q -- p (� ADDRESS ..+A) Newer GCce UCf PHONE#SIO!1� RUB CONTRACTORGrGsa, J.,,, S.'IN }�� 55O F{OV1C anonesehlit•};ne;<icw 9'{553 ucf �o�Dyp7 fl MIONE/5lol3l�-�O(j TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ® OTHER CPT.- Growl,tl ,11t,of Sq"?Its��J ❑ INSTALLATION ❑ WELL SYSTEM REPAIR El CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL f I — J HYPE OF PVMPI EL 11 Now ElRepairH.P. DEPTH PUMP SET FT. FIRST WATER LEVO �ry 11OUTor SEnVICE WELL I ❑ OEOPIIYSICAL WELL f ❑ SOIL BORING R � Id DESTRUCTION: It `„o q CO'AN PA QC� m�1;rCL INTENDED USE TYPE OF WELL CON$TRUCIION SPECIFICATIONS -- NO Cops}CL1c n A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCT On CASINO n ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEFIR'VC DIA.OF WFtt CASINO ❑ PURUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION n 11 IRRIGATION/AG ❑OTHER INR p� GROUT SEAL STALLED BY GROUT BRAND NAME E Ip MONITORING It 'AA9Q GROUT SEAL PVMPFD: ❑Vera ❑No CONCRETE PEDESTAL BY DRILLEn:[1Y- ❑No 5 APPROX.DEPTH 1D 'Pf. LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONeTRUCTIONIMLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER_ 1 HERFBV CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THF WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND nULFB AND REGULATIONS OF THE RAN JOAQUIN COUNTY, HOME o%,vNtn On LICENSED AOFNT'S SIGNATUnF CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR Wt11CH 71418 PERMIT IS ISSUED,I SHAM NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HINNO OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CITIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEnMFF IB ISSUED,1 814ALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA AP ANT $T CALL 24 HOLM$IN ADVANCE FOR ALL REQUIRED IN$PEC N$AT 120$)4"4423. OMPLETE AT LOWER AREA PROVIDED. Tltle - i PLOT PLAN 10, to Sa elel Saele "to oSo c J, 1. NAMES OF STnEFTO OR ROADS NEAREST TO On SOUNDING THE PROPERTY. 1, LOCATION OF HOUSE SEWAGE DISPOSAL BVSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OU7I INFB AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, We 1 Ra - - — _.............:. :. .. ...: _. N DEPARTMENT USE ONLY -7 /.' Del• ."� JA,-- y �c. Applleellen Aoeepied By ,_ �� /-,:_l �� -� _ % "7 O—A I—P-tlon By _- Det. y - /Pump I/nepe-etlon By �/� p� DNe Ueelrucllen Imp-11—BY_,±��r '-(ti r/ �1 L 1../l.il l.�lY.( G!�-CSG[ D.I. -i�g' ©� ACCOUNTING ONLY: AID# FACE i PE CODES FEE INTO AMOUNT REMITTED CHECK#RCAIIH RECEIVED By DATE PERMITR$ERVICE REQUEST NUMBER INVOICE � 'I C Pub.Health Serv.-Enviro.173(3/96)