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APPLICATION FOR WELL)PUMP PERMIT i! 1_4AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BQX 38Q 304 EAST WEBER AVENUE, STOCKtON, CA 9Mi W (209) 466.3420 ,i NON•REFUNDARLE PERMIT EXPIRES I YEAR FROM DATE ISSUED MomPI$I$In TripRe:lel .1 APPLICATION IS 1IERE BY MADE TO THE SAM JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANb1OR INSTALL THE WORK 6ESCRIRED.THIS APPLICATION IS MADE IN COMPUTANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1 115,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APNI x/2-0 �yfPARCEL BIZEJAWV! J OWNER'S NAME, i y sywG y'� _ADDRESS _ /4I'� I G•% ONE/ g �' /Ow y CONTRACTOR_ded r4e�_ .� �.�lQ.. `1 LICK PHONE8 r:) y BUB CONTRACTOR-- _ -A$ �.ADDRESS +# / SG"� liticPHONE A' TYPE OFA, WELLIPUMp ❑ NEW WELL ❑ REPi,ACEMENT WELL ❑ MONITORING WELL N ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR 11 VAPOR EXTRACTION WELL J ❑Naw❑Repel, H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL ROPE OF PUSPI p T- ❑ OUOP-BERVlCE WELL ❑ GEOPHYSICAL WELL I 1-'T SOIL BORING ❑DESTRUCTION: II 'I INTENDED USE TYPEOF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION_ _ Irl rh it DIA.OF CONDUCTOR CASINO U ❑ DOMESTICIPRIVATE ❑GRAVEL PACKIBIZE TYPE OF CASINGIStEEL/PVC II DIA-OF WERL CASING D ❑PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 11 SPECIFICATION R ❑,/IRRIGATIONIAO 11 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME_ ' _ Ira E MONITORING GROUT SEAL PUMPED: [I Y. Na II CONCRETE PEDESTAL SY DRILLER:❑Yw ❑Ne S APRROx,DEPTH LOCKING CHESTER BOx18TOVE PIPE II S PROPOSED CONSTRUCtIONIDItlWNO METHOD: MUD ROTARY AIR ROTARY AUGER '1 CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SANUOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'IICERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR 1NtltCH THIS PERMIT IB ISSUED,161RALL NOT EMPLOY PERSONS SUBJECT TQ WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERBON8 SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.'}T APFYIC NT MUST CALL 24 NO S IN ADVANCE FOR ALL REQUIRED INiPECTION$AT 120$x1 40$3122. COM" DRAWING AT LOWER AREA PROVIDED. EO^ed x Title 6s,010--11-t. Dne__r- _. PLOT PLAN(Drew.to SeNel SON& •toI 1, NAMES Or STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, ,4. LOCATION 2. OUTLINE gN OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSEp OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, E%PAN8ON F SEWAGE DIAGE DI HOSTESS. 3, DIMENSIONED OVTLINF.8 AND LOCATION OF ALL EXISTING AND PROPOSED �S. LOCATION OF WELL*WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY, I - i .. ....: .. .. _ _ - I DEPARTMENT YUSE ONLY 1 ,I Arw Omit M»pxrlon SY Date Pump InoPeetten By I Dote beetruellen tnepeerlon By I Date Comments: a I� ACCOUNTING ONLY: AID/ FACT II II PE CODES FEE INTO AMOUNT REMITTED „CH_ECK$ICABH RECEIVED SY DATE PERMITISEAVICE REQUEST NUMBER INVOICE i Pub.Health Sam-Enviro.173(3/96) I r•�T I1E''/