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!l Y fie>APPLICATION FOR WEL PUMP PERM SAS OAQUIN COUNTY PUBLIC HEALTH SE ,CES ENVIRONMENTAL HEA TH DIVISION 304 EAST WEBER AVENUE,S CKTON,tiCA � I g HEALI-iI (209)468-340' F .1'4C MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IONSTR C in TRIP ItINS � � � 2. 01 -APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FORA PERMIT TO CONSTRUCT ANO70 INSTALL THE CFV E .THIS APPLICATION IS MADE IN COMPLIANCE WRH SAN JOAQUIN COUNTY DEVELOPMENT TRLE:CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAOUI COUNTY PUSUC HEALTH SERVICES,ENVNONMENTAL HEALTH DIVISION. JOB ADDRES6roR APNI. N B S Ya S t=m R'C A✓L W15 „. $ Mptvi_ (,q r PARCEL 81ZEfAPNN �� `l53 OwNER'8 NAME /7 ILI�. GA �. -f ETEf1.8 �{J,+l,f.T si�CAA} 81"TL�1L1I,DOFSE68 VE PHONE rp�1 — �d Q �q CONTRACTOR �c -- -C •-, _ ADIMEss -* p GvfC(�/-� 0� �PHONE r rr��I 1�•�Z� SUBCONTRACTOR�P6C'(7��1M CYPLOAPM 0 2365' W16wht2 -ORES 7�C�-WN �ISZ-mr (Ci 7w'. 8 PHONEt�09 TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING VVELL R ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNI CT REPAIR © VAPOR EXTRACTION WELL ❑New 11Repslt H,P. DEPTH PUMP SET FT. FIRST WATER LEVEL d (TYPE OF PLIMPI ❑ OUT-OF-SERVICE WELL ❑ OEOPHYSICAL WELL IF © roll.BORING g _)2fBESTRWCTfON: LA)— INTENDED !INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIC NO A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISME TYPE OF CASINOISTEEUPVC VIA.OF WELL CASINO p ❑ PUBLICIMUNICIPAL ❑Of"vEN DEPTH OF GROUT SEAL SPECIFICATION p ❑ IRRIGATIONIAG ❑OTHER GETOUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED; ❑V ❑No CONCRETE PEDESTAL BY DRILLER:❑Y« ❑Ne s APPROX.OEPTN LOCKfNO CHESTEI I BOXISTOVE PIPE g PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD VOTARY AIR ROTARY AUGER CABLE. OTHER ---- I HMSY CERTIFY THAT I IIAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OROINANCEB,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CE IFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS tSRUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LA S OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT M ISSUED,I SHAM EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL RIEOUIREDpINSPECTIONS IT t2091468-2423. COMPLETE DRAWING AT LOWER AREA PROpVImo. Slpned X �'� Title JC-Ah00- �� / Vole /'�/—C�3 PLOT PLAN Mfew to Seelel Scale 'to 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF TF1£PAOPERTY,DIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. D1MENMNED OITRLIN£S AND LOCATION OF ALL EXISTING AND PROPOSED S, LOCATION OF WELLS WfTHIN RADIUS OF ONE HUNDRED TIFTY FT: STRUCTURES,INCLUDINO COVERED AREAS SUCH AS PATIO@,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. 1'' P Jqfta c,� ecc .......... .` ... DEPARTMENT U81 ONLY 7 ' App4cotlen Aem,pted By \ ✓V Dole `DO�jyee E-11, Apk O.et4 I—Pp ,to„SY Date P—P lmt,o p �BY Date Dea,tt,etbn Inapec,bn BY Dole Gemma,+. 11'1 r O rn ! b IrkLo r s c [ -�- h ACCOUNTING ONLY: AlOI FACE PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECBVED BY DATE POWITISFJRVICE REQUEST NUMBITI INVOICE O .D6 I058 3/11/0. _SR 35 3R $ Pub.Health Serv.-Pnviro.173(1/97)