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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420� /f)NON-REFUNDABLE PERMIT EXPIRES 1 MEAN FROM DATE ISSUED ! l �Q0-3 (Complete In TripRe$tal APPLICATION IS HERE BY MADE TO THE SAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDRIR INSTALL THE WORK DESCRIBED.TH18 APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-,1[1/111�5..3r AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HE TH SERVICES,ENVIRONMENTAL HEALTH DIVISION.JOB AOORESS/OR APNI I1mo c— L .7 / +CL>'T C� t CITY PARCEL 81ZE/APN/ OWNER'S NAME e—\(/ JtD'�(j�'� ADDRESS NE I CONTRACTOR_—n^v(p`L �PHONE .;2� SUB CONTRACTOR ADDRESS LIC9 PHONE TYPE OF WELUPUMRh ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑WELL TEM REPAIR ❑ CROS"ONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J k� ❑N.A Repel H.P. DEPTH PUMP 9EV4 FIRST WATER LEVEL _ O ITYPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELLI ❑ SOIL BORING 8 ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O IFOOMESTICR'RIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yee ❑Ne CONCRETE PEDESTAL SY DRILLER:❑Vee ❑Ne S APPROX.DEPTHf(G.� / LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CON$TRUCTION/DIILLLNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HE9EBY CERTIFY THAT 1 HAVE PREPARED THIG APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'$SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT M TILE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 04ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HMIHO OR 81.1"ONTRACTIKR BIONAT CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORM OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,i SHALL EMPLOY PERSONS SUBJECT TO WORKMAN•$COMPOIS N LAWS OF CAUFORNI A=MUSTCANO ADVANCE FOR ALL REQUIRED 7*1010�i TION$AT["Of 400-W". COMPLETE DRAWING AT LOWER AREA PROVIDED. 84p,ed X Tltle Date A7 9 PLOT PLAN IDrew to Scale)Seale 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. • �C"$ _- mac. : 4112-Z f05 PAYENT 0- C Y� RECEIVED MAR 32000 SAN JOAQUIN COUNTY j PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ILt DEPARTMENT USE ONLY Application Accepted B�-� Date �! Oreut Impeetten BY Date Plenp Inepactlon BY Oete Deatn.tlan Impaction 8 100te Ce—ante: ACCOUNTING ONLY: /UDI FACT :DL PE CODES FEE INFO AMOUNT REMITTED CHECKI AfH RECEIVED BY DATE PEWIT/SERVICE REQUEST NUMBER INVOICE 10 3131 Pub Health Serv.-Enviro.173(1/97)