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APPLICATION FOR WEL11PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION PA BOX 386, 304 EAST WEBER AVENUE, STOCKTON, CA DMI- 88 (209) 468.3420 11011-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cemploh IN TT1pnestol APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW(DESCRIBED.THIS APPLICATION 06 MADE IN COMPLIANCE Wtt14 SAN JOAQUIN COUNTY DEVELOPMEITT TITLE,CHAPTER B-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESSOR APNI.. D 19 7 1S,t IL �t CH-r j� /� O [yt f!/ /�1 PARCEL BIZEIAPNI (,� f OWNER'S NAME f� O I L y�r,,.,..1 D1'V'j ,gh�Wp -jr ADDRESS 1�]/jjlJ��/ J� �[ 1/ /' PHONE• LV +/ CONTRACTOR__ r✓• /TY! C- ^ AbbREee �qIJ+(Y'Y' II�Y�II LIC! RUB CONTRACTOR A, -_ V r k e ..I�Jry c_ .,-. AbbRE88� 1] 1�' t l'T 4f Uc/_ ,?PHoNE 1 l rI-I f -/'1+ TYPE OF WELLMUMN ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I © OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR VAPOR EXTRACTION WELLI ,/ ❑New ElReoelr H.P. DEPTH PUMP SET FT, (TYPE OF PUMP/ RST WATER LEVEL p ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELLN SOIL BOWNO ee ❑DEBTRUCTKIN: INTENDED USE TYPE OF WELL CONBTRUCTION SPECIFICATIONS f/g Z A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION D .. DIA,OF CONDUCTOR CASING ❑ DOMESTICIPWVATE ❑GRAVEL PACK/SIZE TYPE OF CASINOm rEr IWC Afl l nn _ DIA.OF WELL CASING ❑ PUSUC/MUNICIPAL L1 DRIVEN DEPTH OF GROUT SEAL_ 7E (Au/ -t— SPECIFICATION IVIA rr g ❑ IRWGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY C KR, 9101f GROUT BRANO NAME MMONITORINO GROUT SEAL PUMPED: ❑Yeo PLNo CONCRETE PEDESTAL BY DRILLER;FP �ys� ❑NO S APPROX.DTH , v LOCKING CHESTER BOXISTOVE PIPE S PROPOSED CONSTRUCTIONIdtlLLING METHOD: MUD ROTARY AIR ROTARY AUGER GABI,�LE OTHER V ed!Ga,rf/ � I"MITY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS Of THF 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,1 SHALL NOT EMPLOY PERSONS BUBJECT TO WORKMAN'S COMPENNATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' THE NT MUST CALL.24 HOURS IN A CE Foq ALL REOUIRED INIPECTIONS AT t"61 44111-2422. COMPLETE DRAWLING AT LOWER AREA PROVIDED. f �J Blpned X TRIS_ rF VI L re�7 0? C'kt L 1 �Q !(f,l l.f 1 ATbSte �J PLOT PLAN ID-ow to Score)Seale 'to --"t I. NAMES OF STREETS OA ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED i, OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTUNE8 AND LOCATION Of ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. " '� ±:.�v ON THE PROPERTY OR ADJOINING PROPERTY. - - .... ...... ........... .......... ............ . _ DEPARTMENT USE ONLY APPllaatlen Acoopled By. Dote Ates Groot Impoe len By Date Pump 1nopeellon By bele beal't.11en Irnpectlon By Data C/mmeeMs: ACCOUNTING ONLY: AIb4 FACT PE CODES FEE INFO AMOUNT"EMITTED CHECK;!CASH RECEIVED By DATE P9IMITI4ET;VICE REQUEST NUMBER INVOICE } Pub.HeaRh Serv,-Enviro.173(3/86)