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C9015 -01;p APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201386 (209) 489.342D NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICamplEte M Triplicate) APPLICATION 19 HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WTH SAN JOAQUIN COUITY DEVELOPMENT TRLF, CHAPTER 9-111 S,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE0. ENVIRONMENTAL HEALTH DCWSION. JOB AODREBBIOR APW /J� 5._ d /I ' CITY ` T' a.r � . 6- �Mi-�f'%6 PARCEL a2UAP44/ eye' OWHER'B NAME J ) %P AOORESS�l^/- CONTRACTORS nG y /J/ n j �C Yf%[ Ey ADDRESS N' ' J/l S I SUB CONTRACTOR ADDRESS �v (/ ` 2k LCI PHOW f TYPt OF WELLRyMP ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONO ORINO WELL 4 ❑ OTHER_ ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRDBB-CONWCT REPAIR ❑ VAPOR EXTRACTION WELL # J ❑ IM++lpJ1r#.It H.P,� DEPTH PUMP SET_,�j�FT. FIRST WAT4A LEVEL�r� O (TYFE OF PIMPI !! ❑ OUT OFSKMAC£ WELL ❑ GEOPHYSICAL WELL # ❑ BOIL BORING S ❑ DESTRUCTION: IIryN�TFIwEO USE TYPE OF Wfl1 CONSTRUCTION SPECIFICATIONS A MI L -J INHTNAL F❑F-T� OPEN BOTTOM DIA. OF WELL EXCAVATION FAA. OF CONDUCTOR CASINO O ❑ DOMENTICI'RVATE U GRAVEL PACKMIZE_ TYPE OF CASINGISTEEUPVC DIA. OF WELL CANNO D QI-� PUBLICIMUNICIPAL ❑ DRIVEN DEPTH OF GROIO SEAL _ SPECIFICATION R 0 MRIOATIO WAO ❑ OTHER GROUT SEAL INSTALLED BY � GROUT BRAIM NAME E ❑ MONTTOFNNO OAOUT SEAL PUMPED' ❑ Y.. ❑ 7J. CONCRETF PEDESTAL 1Y DNLLPR; ❑ Y— ❑ N. s ANROX. DEPTH LOCIINO CHESTER BOXMTOVE PIPE S PROPOSED CONSTRUCTIONIDNLLING METHOD: SND ROTARY_ AIR ROTARYAUGER CABtf OTHER 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE N ACCORDANCE NWTH SAN JOA UIN CCIVNTY ORTWAK'ES. STATE LAWS, AND FILES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, /TOME OWNER OR LICENSED AOENT'S BIONATURE CERTIFR:S THE :-0LLAVRNO-'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMT IS ISSUED, I $HALL NOT EMPLOY PEABONS SUBJECT TO WORKMAN'S COMPSAISATIHt LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR "-CONTRACTING SIGNATURE CERTIFIER THE FOLLOWING: ' 1 CERTIFY THAT N THE PERFORNI112CE OF THE WOR( FOR WHICH THIS P[RMfT RB ISSUE[[, I SHALL FMPIOY PERSONS SUBJECT TO WOPIOAIW'S COMPIDOSATION LAWS OF CALRORMA.' ' CANT M T CALL M NO M ADVANCE FOR ALL REOUR® INSPSCTIONS AT 120/1400.8422. COMPLETE DRAWING AT LOWER AREA PRONGED. PLOT PUN ID ' — ' . B.-1 --0 1. NAMES OF STREETS OR ROADS NEAREST TO OR WUN13M THE PKOPERTY4. LOCATION OF HOUSE WWIAGE ONSPOSAL BYBTFU OR PROPOSED Q 2. OUTLINE OF THE PFKYKRTY. 01 -No DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PIOPDSEO S. LOCATION OF WELLS WTHIN RAOIUS of ONE HUNOIED FIFTY FY, STRUCTURES, NCLUDNO COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOIMN13 PROPERTY. �r r�L� MAY - 91997 �P « I\J0R0NlVENTAL HEALTH Djklj I;;,Y R DEPARTMENT USE ONLY APPIicnl.r, Ace.orNa7 eY_ r S ��^t7T - O.t• _ Nw Gr.uI I�I>a,l.n BT_ ON. P,mPIn.Pec tion eY 'rr.J1 �. U�A.,St4 _O.tA L tfr Q� bstructlm Irwp..tM By G.N. c...T...N.- G�Irj17-UA.G� � I:.r�.e,#At�K.s.S+atr IA.NaN.a.f�SEt 4 f:1. 4t U..a3LO- 40 aCc"c 0 -al. ACCOJNTINU ONLY: AID# TACE PE CODES FEE INFO AMOUNT AIDAITTED CHECIU ASH RECOVER SY GATE PWMITISEIINCE AEOUaST M#A9BR INVOICE