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i • R APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 MOIRREFUNDABLE PERMIT EXPIRES I YEAR FROM BATE ISSUED IClmplst,ill TripOrat,) OAPPLICATION 1S HERE By MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1116 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION JOB ADDRESSIOR APNI /1 CITY slw1nAf PARCEL BI;EIAPNP/I CJYet�� OWNER'S NAME pi ADDRESS / & il-0 PHONE s � CONTRACTOR _dZ VIAD'. AN ADDRESS L1Y7 Cf PHONE f ✓ - SUS CONTRACTOR g5 ' ADDRESS 95u A l-1.1 t'14,(' LICE ,r PHONE f nn OF NIELLMUAIP• ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL f '- - ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL f J ❑N.❑R.p.h H P DEPTH PUMP SET FT FIRST WATER LEVEL O (TYPE OF PUMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYMAL WELL I ❑ SOIL BORING 8 ❑DESTRUCTION INTENDED USE TYPE OF WELL CONSTRUCTION IH•ECIRCARONSA A 11INDUSTRIAL [3OPEN BOTTOM OIA.OF WELL EXCAVATION ,IQ If VHA.OF CONDUCTOR CASfNO SAIA P 11OOMEBTICM'AIVATE ❑GRAVEL PACKIBRE /L TYPE OF CABMffrEEL/PVC l vVe—1 DIA.OF WELL CASINO a 11PUSLICIMUMMAL ❑DRIVEN DEPTH OF GROUT SEAL4% I.a&le PeWv 4 SPECIFICATION R ❑ mmoxnGN/AG ❑OTHER GROUT SEAL INSTALIJM BY N �C� GROUT BRAND NAME E L8 MONBTORINIG / GROUT SEAL PUMPED ❑Y. No CONCRETE PEDESTAL BY DRILLER.tdYo. ❑Ne S /APPROX.DEPTH ?J LOaONG CHESTER BOX/STOVE RPE F! P,)A S IK PROPOSE!CONSTRIICTION/ORILLING METHOD MUD ROTARY ADI ROTARY AUGER_ CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES St ATE LAWS AND RULES AND PEGULATIDNS OF THE SAN JOAQUIN COUNTY HOME OWNER OR LICENSED AGENT S SIGNATURE CERTIFIES THE FOLLOWING 'I CERTIFY THAT IN THE PERTORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED 1 SHALE.NOT EMPLOY PERSONS SUBJECT TO WORKMAN S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTO"HIRING OR BUB-CONTRACTINO SIGNATURE CERTWtES THE FOLLOWING 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT re ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN S COMPENSATION LAWS OF CALIFORNIA.' T HOURS!1'1 ADVANC[FOR ALL RIEOURt�INSFL>CTIORQI AT 12/081 MSi42, COMPLETE DRAWINlG AT LOWER AREA PROVIDED) �y 81pne4>< Tlslo © l0!/ Oreo PLOT FLAN Wvr to ScoM Sow 'M I NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY A LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR RIOPOBED 2 OUTLINE OF THE PROPERTY GIVING DIMENSIONS AND NORTH DNIECTION EXPANSION OF SEWAGE DISPOSAL SYSTEMS G DIMENSIONED OUnV0S AND LOCATION OF ALL EXISTING AND PROPOSED S LOCATION OF WELLS WRImf RADIUS OF ONE HUNDRED FIFTY TT STRUCTURES INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS,AND WALKS ON THE PROPERTY OR ADJOINING PROPERTY ~ I F f Ei DEPARTMENT USE ONLY App"mt%n^wetted 9v Gnm In.p..tlen BY Dna PtNnP b"Poffd—BI' dojo D�to DAnwtien 6+opo.IGett BY e cetnfnene. D -�-{ ACCOUNTINO ONLY AIM PACO PE CODES FEE INFO AMOUNT RMTTED CHECIWACASH RECEIVED BY DATE PEGWBT/SOMCE REQUEST NUMBER INVOICE Pub Health Sery -Brnnro 173(1197)