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I I i a APPLICAT16N FOR WELLIPUMP PERMIT SAN JOADUIN COUNTY PUBLIC HEALTH SERVICES AEN� ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 344 EAST WEBER AVENUE. STOCKTON, CA 55241388 (209) 468.3420 ? 9 t°stir QF NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED °- +TL•; r �cc 1Compl$t$in Tttp{iat$1 ETION IS�1 j€pDB�IlMA01:'i'O'+j'61 N JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN OP6'E{O6-�4LL1,r'ZIU*ER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH OMSION. JOB ADDRESSIOR AO _ �/ PARCEL SIZEIAPNI OWNER'S NAME © /o AC1&6_ "ADORESS U&&Z140q7,S� -r �7_1 PRONE�r I .�4Zi -L. 4 CONTRACTORc C. n4✓1� G} 1Ui; fN� PHONE 17 s. 7 a SUB CONTRACTOR ADDRESS tlClr PHONE A TYPE OF MP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r J ❑Naw❑Rwp dr H.P. DEPTH RUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUTgF-SERVICE WELL ❑ OEOPHVBICAL WELL/ L ❑ BOIL BDRMIO e �dDESTRUCMN: „ - ° �E'x3_ Li�hr�`c7Y'11�r� (�1,��IS. L'c�— Q l:r S�3c.i5 -f�ft SCr�xs� INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ OOMEST mmvATE ❑GRAVEL PACKMZE TYPE OF CASMIGISTEEClPVC DIA.OF WELL CASINO D ❑ PUBtICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GLUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yes ❑No CONCRETE PEDESTAL BY DRILLER:❑Yw ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONAMUJN13 METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE9ESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES ANC REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGEWrB SIGNATURE CERTIFIES THE FOLLOWING:1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICI THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-$COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTAACTING SIGNATURE CERTIREE THE FOLLOWING;-,' CERTIFY 344AT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I9 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN-6 COMPENSATION LAWS OF CALIFORNIA t MUST 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPOCTIONA AT 12001480-3423. COMPLETE DRAWING AT LOWER AREA PROWDED. G Sloned X Tlth 'rJu� � oat. / /0 T// PLOT PLAN(Draw to Soshl Sark ro 1. NAME OF 8 OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. ' 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED - 2. OUT E O THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DTSPOSAL SYSTEMS. ., 3. DIM NED OUTLINf.9 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. I .E.....;.. .... .... ..i.. .E..-. .i ..i. ...;.. :.. ..i.. .. I. .... ............:... ..:......:.......=...-...............:..-..:.... .. - .-... .. .. -- -... - .. .. .- .. .. .. (E: .,....',.......................i....J...... .. .. .. .. .- .. - - --. .. .. - .. -........ -.. .. ----- .... .. ............................................... //.\..:. ...2. mss}: -' ...i.. . - ...;..! A...... ... ......: .. :... M . : ..:.., �., .. . .. ':......................... .......... - ..... ... i . : .. .. .. Grwt Mepectlon By ,R Oste 1LZ14 lc Punp I..,.I n Bye Dats t Oomt t tlen IrSyoctlon By r Osta � Cemmerna; Iyl •�. �� i r��' .p �rr ACCOUNTING ONLY: AID! FAC! U Z PE COOEB- FEE IN .,AMOUNT REMITTED CNECKIICASH RECEIVED BY DATEy--- P9tM1T1dERVICE REQUEST NLRMSER INVOICE ►r ,w. 4 a