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APPLICATION FOR IWELL►PUMP PERMIT USAN JOAQUIN COUNTY PUBLIC HEALTH SERVICIW ENVIRONMENTAL HEALTH DIVISIOfj P.O. 60X 388,304 EAST WEBER AVENUE, STOCKTON. CA 95201-388 (2091460-3420 1100-REFUODABLE PERMIT EXPIRES 1 YEAR FROU DATE ISSUED Womploto iR TripReote) 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 WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNO �` LAS V (� CITrKa.Qn PARCEL SIZE/APNO OWNER'S NAME Mai 1 t lJU r pi- Tr ADORES-_ , 3 y.� w , G{ 6 r Vc- / /n� p -/ PHONE#-I CONTRACTOR I'tC�JnK� n � .) t,I Jn4 ADDRESS �j h t 9Sho2b! ti LICA' p OZZ PHONE I � SUB CONTRACTOR r' ,9vt,-w1 71 y ADDAES- �5 F• /I►I�L•I41r,�. UCO 6 Z Z PHONE# �j T/S/5/ TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL O Iq OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL O 11 J New❑Rapalr N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL (TYPE OF PUMP) p ❑ OUT-Or-SERVICE WELL ❑ GEOPHYSICAL WELL# SOIL BOMNO 2 B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_ " A ' 2 1 DIA.OF CONDUCTOR CASINO_'Ve p ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEELIPVC Ad DIA.OF WELL CASING N ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL /(�► //r I^ SPECIFICATION N D ❑q IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY �£/t�jrf—iPi_7G GROUT BRAND NAME 'I b .I .M q..,j tt CY MONITORING GROUT SEAL PUMPED: ❑Vs ICI No �-�-� �� p CONCRETE PEDESTAL BV DRILLER:�Vr ❑No 5 APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE V /' S PROPOSED CON-TRUCTIONRxeLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHERTPo I'`O le 1 HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'-SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR-UB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 19 ISSUED,1 8HALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAW-OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGtXRED INSPECTION$AT(2001400-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. l 1 /� Slened X_ rAhl�{TiL� Wil• M.-- TIt1e_ S4AFF- GPO Io Sr)% Data PLOT PLAN(Draw to Scale)Seal* •to 1. NAME-OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINE.-AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. Com; WOW ��G C)a_ _z5 _ )c+,0be� I°/ti wo DEPARTMENT UDE ONLY /_/� Applicatlen Aceepted By Date /� -zkh�Area Grout IoapectIm By Date Purnp Inapectlon By Date Deatrtmtlen ImpecOon By Date CommerNa: ACCOUNTING ONLY: AID# FACO PE CODES FEE INFO AM T REMITTED CHE /CASH RECEIVED BY DATE PERMITI$ERVICE REQUEST NUNIBER INVOICE Ol' 0351/L Pub.Heafth Serv.-Enviro.173(3/96)