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APPLICATION FOR WELLIPUMP PERMIT AAN JOAQUIN COUNTY PUBLIC HEALTH SERVICL.- ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 469.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED_ (Complete In Triplicate) APPLICATION IS IIFRE BY MADE TO TIIE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WTT11 SAN JOAQUIN COUNTY DEVELOPMENT TrT, Ti LF.CIIAPTER 9-1115.3 AND TIIE STANDARDS OF SAN JOAQUIN CO-UNNTTYY-PUBLIC IIEAALTII SERVICES,ENVIRONMENTAL IIEALTII DIVISION. JOB ADDRESS/OR APNS ( -Y .i/ •1-1'x - 7 CITY f � FL SIZE/APNI OWNER'S NAMEzna --�Aia Lt;{� ,�M hRESB_j Z.� �� 107X( S 11r C�e4- P1 TONE I 8 1--yam'7 Zo CONTRACTOR f-/-ril�f/YY'JG-�O�- \ � �)2Jj�JIy10'llly'll__ ADDRf Sg 6 /)X� LICI -7 PHONE I U' Qa'�O OUR CONTRACTOR IT `� ADOnFSP, - -141- t.IC/ MIONE l TYPE OF WELL/PUMP: ❑ NEW WELL ❑ RFrUCEMFNT WELL ❑ MONITORING WELL I ❑ OTIIER ❑ INSTALLATION ❑ WELL 8VSTEM REPAIR ❑ CnOSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ❑New❑Repel, N.P. DEPT 11 PUMP SET FT. FIRST WATER LEVEL O H VPE OF PVMPI ❑ OUT-Or SERVICE WELL ❑ OEOPIIYSICAL WELL I B<.-IL PORING g ❑DESTRUCTION: INIENDED USE TYPE OF WELL E6"TRUC110N SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION -4) 1 1 DIA.Or CONDUCTOR CASINO /VA- D ❑ DOMESTIC/MUVATE r❑l GRAVEL PACK/SIZE TYPE OF CASING/STFEL/PVC A-) ,., DIA.OF WELL CASING ❑ PUBUC/MUNICIPAL LYf DRIVEN DEPTH OF GROAT SEAL /^'1 7 Vy�i1-'fin SPECIrtCATION �A� R ❑ryI/RRIOATIO N/AG ❑OTHER GROUT SFAL INSTALLED BY y�-y�i�4�C-G.. OROIIT BRAND NAME q� }��/ E IYJ MONITORING ` GROUT SEAT-PUMPED: ❑Ye• L7 No CONCRETE PEDESTAL BY DRILLER:❑Yr U No S APPROX.DEPTH LOCKING CHESTER BOXlBTOVE PIPE S PROPOSED CONSTRUCTION/DARLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE. OTHEf1�SF-P,�,�- I IIEREBY CERTIFY THAT I/IAVE PREPARED THIS APPLICATION AND THAT THF WORK WILL SE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. IIOME OWNFR OR LICENSED AOENT'S SIGNATURE CErTTIFIE6 THE FOLLOWING:'I CERTIFY THAT IN TILE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIfORN1A.' CONTRACTOR'S HIRING OR SUR�CONT RACTINO SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN TIM PERFORMANCE OF TIM WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA/.- T,H'�APPLICANT/MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTI/ONS AT 12091 460-042]. COMPLETE DRAWING AT LOWER AREA PROVIDED. /(� Slpn•d X V�/({/l/L,YT/L�(/' (, � Thle �I ` D�j i 1 Date 7/04 ` J PLOT PLAN ID—1.So•lel tlo•le "to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF IIOUSF.SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. DFPAATMFNT USE ONLY APPIT-0-Aooepled By--w Grout Impeetlon By Dale Pump I-peellon By Dela De•Ine:llen ImPecllon By I� D•le Commd,le:_—I��C ' 171.4i�'Sfi. w?�/1�('� c,1'�1 A A6 ACCOUNTING ONLY; AIDI TFACI i` I Tk _6 `5`� OE CODES FEE INTO AMOUNT REMITTED CHECKIlCASH_I RECEIVED BY DATE PERMIT/6FTIVICE REOUESi NUMBER INVOICE TO Pub.Health Serv.-Enviro.173(3/96)