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APPLICATION FOR WELL)PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI ENVIRONMENTAL HEALTH DIVISION ill 304 EAST WEBER AVENUE,STOCKTON, CA VM1 X86 (209) 468.3420 i I F NDN-REFUADABLE PERMIT EXPIRES T YEAR FROM DATE ISSUED (Comptitb In TripRcehl APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9J-111115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBUC/HEEA-LLTT 11 SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AHJbRE99A7R APNfi 6�' L.J�00141 nh r/- /,Z�T y�� CIT{ J '`I� I Q/V PARCEL BI2FlAPN/ �Q G�L�@d �F OWNER'S NAME. a7 t>CKT'1/V GNI F160 J CITG! VIJ!/AtlUfl> �(r r/V -I.. Z)17-IVF— PHONE 7-"• CONTRACTOR__/_ fl-- TE/e_.- ��15!/]�@rYnS� ! T AbDAE98 'r I,JCfi✓� d�� PHONE/ rQ ��Z, �� BUS CONTRACTOR AbDREeS! `-' R'(e/{LAPAID ucfi PHONE fi t ,y Ih ITYPE OF WELUPUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL N �.P � ❑ OTHER t : t ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR jl ,'i ❑ VAPOR EXTRACTION WELL Of J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O {TYPE OF PUMPI ❑ �:OUT-ORSEIY RVICE WELL ❑ OEOPSICAL WELL fi iI �BOIL BORING I i ❑DESTRUCTION: 1 'I �GP C P(C.T/1 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS :1 A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION M VIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINO/STEELMVC J DIA.OF WELL CASINO p ❑ PIBLICIMUNICIPAt ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION A ❑ IRRIGATION(AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME D Gifal ❑ MONITORING GROUT SEAL PUMPED: Ely— ❑No � CONCRETE PEDESTAL BY DRILLER:[3Y. ❑No S E}E APPROX.DEP'T04 LOCKING CHESTER BOX/STOVEPIPE PROPOSED CONSTRUCTHONIbRILLING METHOD: MUD ROTARY AIR ROTARY AUGER !I �I CABLE pTHEq. �Q� ffff I 1 �I I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:[-I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING on SUB-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAM-8 COMPENSATION LAWS OF CALIFORNIA. T MUIIT CALL 24 HOURS IN ADVANCE FOR ALL REQUSIEO 1 SPEC"OPY AT 120111 4"342S. COMPLETE DRAWING AT LOWER AREA PROVIDED. i; g I Q Slpned X Ee -- Title �_ Vate 1 PLOT PLAN ID,a to Saala)Scale "to I� ' 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE OIBPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION- iEXPANSION OF SEWAGE DISPOSAL SYSTEMS. LI ' 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED r S. LOCI TION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. i STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS AND WALKS 1 N TI! PRO PERTY OR ADJOINING PROPERTY. . E _ ..; I _... I I ., t I! ' r DEPARTMENT USE ONLY Application Aaaepted By Date AIM Greta Ilmpmtlen BY `IyI Data Pimp InaPeaHen By I I� Dole Death flen Impxtbn By I� Date comm«�.: er.NLl.+ LS;s u ed Go,nc�.lfiv, S s4-,}-ed p1"5/fdJ2 16w1fasp011 d _ :22_ W- ACCOUNTINO ONtY: AID$ FACT PE CO Ell FEE INFO AMOUNT REMITTED CHECROMASH RECEIVED BY DATE ;' PBiM1TleH71VICE REQUEST NUMBM INVOIcE 35C2 �3Z3 g.(zr9 r 330 I Pub.Health Serv.-Enviro.173(3/96) l ii