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APPLICATION FOR WELLIPUMP PERMIT 0 OSAN JOA(IUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION �G _ $ _F- A. BOX 3K 304 EAST WEBI_R AVENUE`, STOCKTON, CA VM1-388 Z 1299) 468-3420 NON-REFUNDABLE PERIN[f EXPIRES 1 YEAR FROM DATE ISSUED [Complete In Trlp[ienta} APPL1CATWN IB HERE SY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOJOR INaTAL1 THE W0APf DESCFOBED.TTNB AMICATION E WCO JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1115,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL IHEALTH DIV151(UAHCE WITIf SAN JOB ADDRESSrotI APS/ CITi 1 S PARCEL s1ZE/APNI 1 , r - OWNER'S NAME 1 --77 IQJ1 TE'� AODRES$ PHONE 0r�� CONTRACTOR ADDRES.—r PHONE I I HUB CONTRACTOR r-1 ADDRESS LICt PHONE t nM OF WEL P IMP: 13 NEN'WELL ❑ REPLACEMENT WELL �,MONITORING WELL R ❑ OTHER 11 INSTALLATION 11WELL sYRTEM REPAIR ❑ CROSS-CONNFC7 REPAIR ❑ VAPOR EXTRACTION WELL# � RYPE OF RRMPI 11New L3 Rapelr KP, DEPTH RUMP SET FT. FIST WATER LEVEL A - ❑ OUT-OF SERVICE WELL 11 .3EORIYStCAL WELL 1 �bOIL ROM14G g 11 DESTRUCTION! INTENDED USE TYPE OFWELL CONSTRUCTION SPECIFICATIONS Af A ❑ INDUSTRIAL ❑OPERA BOTTOM DIA.OF WELL EXCAVATION--'I �4 DIA.OF CONDUCTOR CASINO p ❑ DOMEQTICIPRIVATE ❑G VEL PACKfsIZE TYPE OF CARINOra7EELIPvG fit DIA.OF WELL CASINO 11PUBLIC)MUPOCIPAL DRIVEN DEPTH OF GROUT 6EAL r HPECFFICATIOH p ❑ IRRIGATKINIAG ❑OTHER GROUT SEAL INSTALLED BY L� GROUT BRAND NAME £ 0MGMTORING GROUT SEAL PUMPED: Pay. [IN. CONCRETE PEOEBTAL By DRILLER:11 Yr 12'N'o 5 APPROX.DEP7HLOCKING CHER TER BO}t19TOVE iMPE5 PROPOSED CONSTRUCTIONfDWLLMO MFTHOD; MUD ROTARY` AIR ROTARY AUGER _CABLE OTHER I HE WSY CFRTITY THAT 1 IPAVE PREPARED T1419 APPLICATION AND TIAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAH JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOADL9N COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLL0VMO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIN PEmu9T IB ISSUED,1 SHALL NOT EMPLOY PERBONs SUBJECT To WOOKMAN'S COMPENGAnON LAW$OF CALWORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING staNATURE CEPRIFIEs THE FOLLOWING: 'I CCRIIPY T T IN TPIE FORMANCE OF THE WORK FOR WHICH THIS PERFAFT IS ISSUED.1 914ALL EMPLOY PERSONS BUNJECT 70 WOR04AN-9 COMPENSATION LAWS OF CAL1FoRNlA,' T ANT T CALL LOURS IN ADVANCE FOR AL,REQUIRED INSPECTIONS AT 1�%001•S'I.742S. COMPLETE DRAWINNO AT LOWER AREA PROmMO. Blpne.0 X T1tle �-I bele PLOT PLAN{Drew ie Deelel 9eele 'to 1. NAME OF STREETS OR ROADS NEAREST TO OR BOUNNDING THE PRoTERTY. 1. LOCATION OF HOUSE SEWAGE OIBPO$AL SYSTEM OR PROPORED 2. OUTLINE OF THE P110PERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISMSAL SYBTEMB. 3. DIMENSIONED OUTUNEN AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTLW8,WCLMNO COVERED ARAB SUCH A8 PATIO B,DRIVEWAYS,ANO WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. : :. o: ... � S (/l DEPARTMENT USE ONLY Appllerllen AeeepleA By ` r !!. Dete !/"v LJ A.aa Grein Impmtlon Byz '✓V U Date p ImPeaiten By QNO beNnrctlen Impwtlen Sy / Comme.we: ACCOUNTING ONLY: AID/ FACA PE CODEI FEE INTO AMOUNT REMIPTEb CHECK/lCASI4 RECEIVED BY DATE ITliFRVICE REOVEiT NUMBER INVOICE 5C7� a o0 9G � g a S a23G�- Pub.Health Serv.-Envira.173(3/96)