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APPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SEF :S ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON,,CA 4SMj: eAI_TI: (209) 468.3420 , NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUES n ��j 3; 17 (Complete In Triormtel APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WOM DESCRIBED.THIS APPLICATION 19 MADE IN COMP IANCE WITH SA JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-111(11$.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSMR APNI tJl L TTA^ NtI CRY \ PARCEL 91ZE/AMI OWNER'S NAME_S �1 U, I r::r.LI1�CS L 1',.1 ADDRESS r ter. G.IL LIL:1 LG: '. �,::A ( Al PHONE wf7c'I Los- 61 b: CONTRACTOR u f l Ti )�\n C. ADDRESS /��t HuW C 4' I�l'1 .'\C Z LIC! CI tFi]1(O] naNE ii 5T04. SUBCONTRACTOR wr '4 N. ADDRESBI`OrL� �a1.:.1.� L..� Ci.L-(�LN:e RIONE 4�/�, i'•• I. TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REF ACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROBB-0ONNECT REPAIR ❑ VAPOR EXTRACTION WELL ❑Nal❑Roper M.P. DEPTH PIMP SET_FT. FIRST WATER LEVEL (TYPE OF PIMP ❑ OUT-0F-SERVICE WELL ❑ OEOPIYI CAL WELL I BOIL BORING LC(\ �1 ITP DESTRUCTION: Lti.tCE:,�y�- INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING C ❑ DOMESTIC/ VATE ❑GRAVEL PACK/SIZE TYPE OF CASING/HTEELT VC DIA.OF WELL CASING I ❑ MBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION F ❑ IRRIGATION/AG ❑OTHER GROUT SEM INSTALLED BY GROUT BRAND NAME E ❑ MONRORINO GROUT SEAL PVMPED: ❑V No CONCRETE PEDESTAL BY pRIl1ER:❑V. ❑Na 5 APPROX.DEPTH LOMI CHEATER /STOVE PPE PROPOSED CON ITRUCTIONRR&WNG METHOD: MUD ROTARY AIR ROTARY A ER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT RK WILL BE DO Ri ACCORD E H SAN MAGIAN COUNTY ORDINANCES.STATE LAWS.ANO RUIEB AF REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR 11EN6 -I 'S SIGNATURE ERTIFIES THE M OWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHIC THIS PERMIT 10 ISSUED,I SHALL NOT EMPLOY PERBON8 SUBJECT TO WOR AN' OMPpNAT1ON WS OFC ANIS.• CONTRACTOR'S HIRING OR SUB-0ONTRACTIM MNATURE CERTIFIE THE FOLLOWING: 'It CERTIFY THAT IN THE PERFORMANCE O THE WORK 9 CH THIS PERMIT IS(BELIED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS C CALIFORNIA.- THE MUSli 24 HOURS IN AOV CE FOR A REO ED INSPECTION&AT 12O&)4&SJ42S. COMREFE DRAWING AT LOWER AREA PROVIDED. Slmnae X Th L'zc i;i L.r,.,• Gz�� Lr On. I ,'�_ -� h MOT N ID'.to Saalal Sae14 •to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BO DING TH PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PRROPERTY,GIVING DIMENSIONS AND PITH RECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. B. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTI AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS, VEWAY6,AND WALKS. ON THE FROKHTY OR ADJOINING PROPERTY. .. J:LI L. 1 l�-. f' Tr' DEPARTMENT USE ONLY AyPlleellpn Aeegtetl By /�' Data z-L711 , 7 ( ,� Ary 1 Gram Imastlon By Dem Penp Impaction By Data Dynwtlen Impaction By 0.1. Co-:nal ACCOUNTING ONLY: AID# FACT PE CODES FEE INFO AMOUNT REMITTED HE< ICA&H RECEIVED BY DATE PEMSTI&ERVICE REGUEST NUMBER INVOICE 3S 1 - Irl-7; OLl h) J0 kSD 1�