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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIC ENVIRONMENTAL HEALTH DIVISION P,O• BOX 388,904 EAST VIEBER/VENUE,STOCKTON, CA 95201388 (209) 469-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED #Complete In Trlpllentf) APRICATION IS HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCIURED.THIS APPLICATION IS MADE IN COMRIANCE WNH SAN JOAOUIN COUNTY DEVELOPMENT FRI.CHAPTER 9.1115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC IHEALTI SERVICES,ENVIRONMENTAL HEALTH DIM BION. JOB ADORE88/OR APNI ZL� tJ I:IlN, �F/)7Cl' vJ• .-7ec J CITE PARCEL BREIAPH#C OWNER'S NAME �.. /-�L I r- ADDRESS_ / h_. /. J J RHONE It CONTRACTOR I 7 // 1 ADDRESS I:If 4— !1J , OCR /Ll >D PHONE# BUB CONTRACTOR ADDRESS LIC/ RHONE/- TYPE OF WELLIPUMP: ❑ NEW WELL ❑ RERACEMENT WELL ❑ MONITORNO WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CPK)GS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ❑New❑Repel, N.P. FDEPTH PUMP SET_FT. FIRST WATER LEVEL 0 TYPE OF PUMP) _/ ❑ OUT-OF WELL ❑ GEOPHYSICAL WELL I aLl SOIL BORING LU//'-/ !]/'O L Ali-A/ g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUDTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O ❑ DOMESTICA'RIVATE ❑GRAVEL PACK/BRE TYPE /B OF CASINGTEEH/PVC DIA.OF WELL CASINO G ElPUBUC/MUNICpAL ❑DRIVEN T— DEPTH OF GROUT REAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUP BEAL INSTALLED BY GROW BRAND NAME L-:. F ❑ MONITORING ( GROUT DEAL PIMPED: ❑Y. [IN. CONCRETE PEDESTAL BV ORLLER:❑Yee [IN. S APPROX.DEPTHn_ .SL' /w &y LOCKING CHESTER BOX/STOVE PL1PE/ S PTIOPOSEQ CONSTRUCTIONID1eLUNG NUMB: MUD ROTARY AIR ROTARY AUGER V CABLE OTHER 1 HE9FRY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORC WILL BE DONE IN ACCOIHOANCE WITH BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:1 CERTIFY THAT IN THE PERORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,I914ALL NOT EMROY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: ',.CIF&IFY THAT IN TIH PERFORMANCE OF THE 1 OR(FOR WHICH THIS PERMM I8 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' TN[APPIICANT MUST 9A _4 HOURS IN ADVANC OR ALL RE INS NS AT I=Op/SSJItf. COMPLETE DRAWING AT LOWER AREA PROVIDED. A. '`�'f0/ BlSneex G:'i- = •-r...� i: h lT b %/9 (" i!/- '' r%ils J/G - TT Dae PEOT!"N Brew le Social Seas I. NAMES OF STREETS OR ROADS NEAREST TO 6A BOUNDING THE PROPERTY. 4. LOCATION OF MOUSE SEWAGE DISPOSAL SYSTEM OR RroPOSED E. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DInECTION. 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 AroPERIY on ADJOINING VEbPERrv. DEPARTMENT USE ONLY a / Application Aoeep,ed BY � y(,yr�2 Oele Area Onto Inepnallm OF J 0e1e Pimp tolpealan SY Data Deeblcllen Impevllan BY '4 O ✓ Data CemmePlc ACCOUNTING ONLY: AID/ FACT PE CODES FEEINFO AMOUNT REMITTED ICASH RECEIVED by DATE, PEISHITISETMCE REQUEST NUMBER INVOICE Pub.Health Serv.-Enviro.173(3/96)