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APPLICATION FOR WELL(PUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICE.. ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201 X88 (209) 46B-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Compl$ta In Triplicate) APPLICATION IS HERE BY MADE TO TIIE SAN JOAQUIN COUNTY Fon A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.TIIIR APPLICATION 16 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,Cf1APTEn 9-1115.3 AND TIIE STANDARDS OF RAN JOAQUIN COUNTY PUBLIC IIEALTII SERVICER,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APPNI iz �'4'lli-r -It RI7rE/1A10rNNFF// 9QZ/,S;�.—I�/E,,�VROWNER'SNAME /2 - / CONTRACTOR /71itT7► W4L ADDRESS � '�DoNIIONE I BUS CONTRACTOR J ADDRFRS LIC/ $ONE I TYPEOFWELLPUMP: leNEWWELL REPACEMENT WELL 17 MONITOnINO 2]�Q' WELL I ❑ OTHER ❑ INSTAILATION ❑ WELL SYSTEM REPAIR ❑ CnOSS-CONNECT nEPAIn ❑ VAPOR EXTRACTION WELLS'_ 11 N—❑RW.1, HP. DEPTH r'UMr SET FT. FIRST WATEn LEVEL p HYPE OF fLIMPI ❑ OUT-Or SEnVICF WELL ❑ GEOPHYSICAL WELL I ❑ SOIL SOnING q ❑DFSTnUCT1OP4: INTENDED USE TYPE OF WELL CONSTRUE 110N-SPECIFICATIONSS1 A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATIO N� /�-C7 "/ DIA.OF CONDUCTOR CASING A)T/1" p 11 DOME STIC/PLUVAT E ❑GRAVEL PACK/817E TYPE.OF CAMNOMTFI`116 JL�/� L DIA.OF WELL CASING 1:1 P' UBLIC/MUNICIPAI ❑hNVEN DEPTH OF GROUT SEAL G T-p�o SPECIFICATIONC-�w, '-tt p ❑ � 1nnIGATION/AG ❑OTHEn GROUT SEAL INSTAI.LFD BV Z 1 �'1� GROUT BRAND NAME � y�.ra�� 1 N E LSa MONITORING GROUT SFAL PUMPFO: ❑Vw. /{..•�, /�^� CONCRETE PEDESTAL BY ORILLERr y+ [2-N. e S APPROX.DFPTH I;J V( 7 LOCKING CIIF. ER B /RTOVE PIPE S, PROPOSED CONSTRUCTION/DrIWNO METHOD: MIND ROTARY Ain nOTAnV AUGER CARIE OTHER I IIERFRY CERTIFY TIIAT I IIAVE PREPARED TIIIR APrLiC ATION AND THAT THF.WOW WILL BE DONE IN ACCORDANCE WITH RAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO REGULATIONS OF THE BAN JO AOUIN COUNTY. HOME OWNFn On LICENSED AOFNT'8 SIGNATURE CFRTIFIES TIIE FOLLOWING: 'I CFMIFY THAT IN THE PERFORMANCE OF TIIE WORK Fon WIIICII TIIIS PERMIT IS ISSUED,1911AIL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALtronNIA.' CONTRACTOR'S HIRING OR BUR CONTRACTING SIGNATURE CEITTIFIES TIIE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOr1K FOR Wt11C11 TIIIS PERMIT IS IRSUFD,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANTMUST CALL 24 HOURS IN ADVANCE FOR ALL REGLXRED INSPECTIONS AT 12001 49$3421. COMPLETE DRAWING AT LOWER AREA PROVIDED. Blpned X P�.i�_/l-w�� Tttlw ^ k7 Dwte / PLOT PLAN ID,—to Irwelw)C.elw 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING TIIE PROPERTY. 4. LOCATION OF HOURE SFWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PnOPFRTY,GIVING DIMENSIONS AND NORTH DInFCTION. EXPANSION OF SEWAGE DIBPORAL SYSTEM@. 3. DIMENSIONED OUTLINF@ AND LOCATION OF ALL EXISTINO AND PiOPO6ED S. LOCATION OF WELLS WTTI/IN RADIUS OF ONE HUNDnro FIFTY R. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY On ADJOINING PROPERTY. � r Tj� 1 I �//� //� DEPARTMENT USE ONLY on APP11owUA—pled Ry_ O/I_n Ar r O.00l inepewtlon By Dete Rm.p Inennetlen By Oele beanretlen Inr,PecUon By Det. C.--w ACCOUNTING ONLY; AID/ FAC/ PE CODES FEE INTO AMOUNT R ITTED CIIECKI/CASI1 I RECEIVED BY GATE p FTIMIT/a E71VICE RE UEaT NIIMR Ai INVOICE Pub.Health Serv.-Enviro.173(3/96)