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APPLICATION FOR WELLIPUMP PERMIT k..� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, SOX SSB,304 EAST WEBER AVENUE,STOCKTON, CA 95201 88 (2091488-3420 NDN-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in TTlpikets) APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENTTITLE.TITLE,CHAPTER 8-11111.3 N THE STANDARDS OF SAN JOAGUIN COUNTY PUBLIC/HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADARESSIOR Ams 3 I �O r� C Clre J d C L1 t(/V 1/,, 1i, f� /] j PARCEL BIZElA1'NI ^j OWNER'S NAME V A 1' 0 IJ.( A1 Wa ! ADDRESS r/1��•7 ��! ./t/ r D PMNE! L– CONTRACTOR h b 4/)(!/S 5 U hVlrl11 h f#t I I k[- _ADDRESS 3�y 1 W,.)Mf0 A t,? f_vr kA LIC, 610 LL f PHONE ff 456-02-0 JV–U 2-0 C OUR CONTRACTOR!1 j((4101�d_ 6—f 6 ITI(t r,fl Ila ek t4l 1 11 CADDRES3315_t. X11 r I!�/A6 #ri Z LICM �Q 8�INDITE 171+N_51 r TYPE OF WE,LIJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL sYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL e J ❑ RTYPE OF PVMPI New 13Repta, H.P. DEPTH PUMP SET Et. FIRST WATER LEVEL O //.,.� 11OUT-OF-SERVICEWELL ❑ GEOPHYSICAL WELL, IN SOIL BORING VCd Cf g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION ❑ INDUSTRIAL ❑OPEN BOTTOM OIA.OF WELL EXCAVATIONYDIA.OF CONDUCTOR CASINO A114 p ❑ DOMFS ICIP IVATE ❑GRAVEL PACK/BIZE TYPE OF CASINOISTEEt1PVC Tf r // v1 r DFA,OF WELL CASINO D ❑ PUBLICIMUMCMAL ®DRIVEN DEPTH OF GROUT SEALT_- 1 d a1 Oc r f'1 L`SPECIFICAMN 1V T g ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY Ire RIO i 4 GROUT BRAND NAME e q f p © MONITORING �] GROUT SEAL DUMPED: ❑V. ®No /�{ CONCRETE PEDESTAL BY DRILLER:,yCE.Yw N. S APPRo K.DEPTH n' L�O LOCKING CHEBTER BOXISTOVE RPE �!M r S PROPOSED CONSTRUCTION/DRILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 6-06 PV46 1 HE9ESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND REGULATIONS OF THE 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 19 ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN':COMPENSATION LAW13 OF CALIFORNIA.- CONTRACTOR'S HIRING OR SU&CONTRACTING SIGNATURE CERHFIfs THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE CANT MUST CALL 24 No N ADVANCE FOR ALL REQUIRED INSMTIONs AT 1110014SS-3422- COMPLETE DRAWINGAT LOWER AREA PROVIDED. signed X I-h 11 f IrOh I'�'(r YL 1 �..y e C r G+f is_f_ Z— /I— THIe f — pate PLOT PLAN KNOW to Bala)Salve 'to I. NAMES OF 8TREETS OR ROADS NEAREST TO OR HOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL BYBTEM OR R30T'OsED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH b1RFCTRON. EXPANSION OF SEWAGE 018POM SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 8. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTUREB.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. wok It �� : I DEPARTMENT USE ONLY Applicathm Aecepled By Dare At" Orcal Inspection BY Dote Papp In.peelton By Date Deantatlon Inepeatlon By Date Comment.: ACCOUNTING ONLY: AID, FAC# PE CODES FEE INFO AMOUNT REMIT7ED CHECK#!CASH RECOVEO BY DATE r"I ITWERVICE REOUEST NUMBER INVOICE Pub,Health Serv.-Enviro.173(3/96)