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APPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SER*N -S ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 4683420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IOBmpletO In TripliutEl 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 JOAOVIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY e PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN# f';�6 e) y I`( w ko 1 CD, Ltd,) 7� �1 z '� - J P/AAMEL SIZEIAPNI O i I-O5D -3;k OWNER'SNAME -S �( I\ }Oil rV)d( .Cf> �O . ADDRESS P,0, NOX ,TU OL J. (akCi T/V g(/l PHONE AJO -Ili-6/18 CONTRACTOR � 4qY LI' 1Ik1�I) ADDRESS 4TO /rove /� /I-)Q y'fli�j,lD;T S�_PHONEIS1D j(3"`JS4� SUB CONTRACTOR `TJ ADDRESS LJCI RHONE It TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPUCEMENT WELL ❑ MONITORING WELL A ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL f J ❑Now❑Repair N.P. DEPTH RUMP SET FT. FIRST WATER LEVEL O ITYPE OF RUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL f ar SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO O ❑ DOMESTIC/ROVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASING D 11 PUBLICWUNICIPAL ❑DRIVEN DEPTH OF GROUT SEALSPECIFICATION e IF UT BRAND NAM Lai MONITORING G ❑OTHER GROUT SEAL INSTALLED ❑Y. ❑No CO CRETEE PEDESTAL SY DRILLER:❑YM ❑No 5 APPROX,DEPTH LOCKING CHESTER BOX/RTOVE PIPE S PROMISED CONSTRUCTION/DRWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER(_ I HEoEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'!COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'8 HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-/�THHEE�APPPLICA�NT[�M�UST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED I/N/ISSPPECTIONNS-AT 113 )jAN4114M COMPLETE DRAWING AT LOWER AREA PRO VIO•ET/� 6IBn.d X /I✓)3,1 YMnA Tide /IU i e N 6fol oq, 1 7- D.I. �I-r 4-1L16 PLOT PLAN (Drew to Seale)Seals •to t. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. f. 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 OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DW VEWAYS, AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. ee i�wT1� p!ao PAYMEN`L , RF(`r'rtTF� FEB 2 11996 - �aNaOAVUIn L.9LIC.H6LtN sER 1 Y IL RONMENTAL HEALTH D /) ...... . .I........... DEPARTMENT USE ONLY APPIIcetlon Accepted By Dels " � �G Aree Grout Impnotlpn By D.t. Pump Impeotion By Det. Destruction Impnetl.n BY Det. Cpmm. '. ACCOUNTING ONLY: AID/ FAC# PE CODES FEE INFO AMOUNT REMITTED C q8N RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE