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APPLICATION FOR WELLIPUMP PERMIT Sr.AN JOAQUIN COUNTY PUBLIC HEALTH SERVICL ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED (Complete In 7riplketel APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION I6 MADE IN COMFLIANCE WTII SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSER AA., 00 /I E10001 0 ✓J CIT/ PARCEL SIZUAPNI OWNER'S NAME / eAAC- K]t'f CONTRACTOR j��llrl�1111 •a,y.JnY [ QyyL�`7/INj `��P /I(0,�'�ADDRESS -PQR^ PONE E P{ 04I-^;;�374 AODRBR3WCU7& S JiMS RIONE/7M I7D—LOO SUB CONTRACTOR ADDRESS UC) PHONE/ TYPE OF WELLJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CR09&CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ✓ ❑N.cl P.PNr N.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL O PUMP/ OUT TYPE OF MP/ ,^1 ❑ OVTOFSERVICE WELL ❑ GEORIVSICAL WELL I EOR 80RNG T B ❑DESTRUCTION: INTENDEDVSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION 1_�L DIA.OF CONDUCTOR CASINO O ❑ DOMESTICNRVATE ❑GRAVEL PACKISIZE TYPE OF CASINOISTEEVPVC l,-yCIIAA.OF WELL CASINO O El pVBLIC/MVNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL C,k1 r6MATION R r ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY \ GROUT BRAND NAME E ❑ MONITORING ((Jj GROUT SEAL PUMPED: ❑Ys F14, CONCRETE PEDESTAL BY ORLLEE❑Y— ❑N. 5 APPROX.DEPTH �n 'Tre.� LOCKING CHESTEn BOKISTOVE PPE S PROPOSED CONSTRUCTIONEIELUNG METHOD: MVD ROTARY AIR ROTARY AUGER CABLE OTHER I HERERY CERTIFY THAT I HAVE FREPARED THIS APPLICATION AND T14AT THE W,RS WILL BE DONE IN ACCORDANCE WITH SAN JOAUUIII COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE BAN JOAONN COUNTY. HOME OWNER On LICENSED AOEW'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1814ALL NOT EMPLOY PERSON$SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR"S"HUNG OR WU ONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN TIIE PERFOPMIJPI OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED.1 SHALL EMPLOY PERSONS SUBJECTEN TO WOMAIAN'S COMPENSATOR LAWS OF CALIFORNIA. THE_�CANT.tMUST CALL A 11D r( OVANCE FOR ALL REQUIRED INSPECTION*AT 120111 4401431. COMRlTE DRAWING AT LOWER AREA PROVIDED.. TIMI. [ � D.. meeee% MOT-i (D'.m Oe WI Ba.b 'le 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING TI PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OLOUNE OF THE PROPERTY.GIVING DIMENSION$AND NORTH DIRECTION. EXPANSION F SEWAGE DISPOSAL SOF ON 1. DIMENSIONED OUTLINES ANC LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS ADJOWOMINING IVIG PR PE ONE NVNOREO FIFTY R. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAIXB. 1 ON THE P®ROPEGRTY OR AOOJOININO PROPERTI'. [.. .. ... T :.....e ... DEPARTMENT USE ONLY Awlb.Ibn Awwled BY p De. I Mr GroU ImlHclbn er / C.Ie 1 A.nP ImP.4aen BY D.0 61, ACCOUNTING ONLY: AID/ FACS PE CODES FEE INFO AMOUNT REMITTED CHI CKKIMASN RECEIVED BY DATE PEMITISFAVIC£REDDEST NUMBER INVOICE Pub.Health SEN.-EnvirG.173(3196)