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APPLICATION FOR WELLIPUMP PERMIT(---N C7 I SAN JOA(lUIN COUNTY PUBLIC HEALTH SERV1..J f%A ENVIRONMENTAL HEALTH DIVISION PA BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 9=1.388 (209) 469-3420 IIt1N•AJUNDABLE PERMIT EXPIRES I_YEAR FROM HATE ISSU O ICompiets in TTipkats) APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK 01:86RBBED•THIS APPLICATION IB MADE IN COMPUANCE WITH SAI JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. 108 ADCRESSKRR p N#1 1-f� o Vv L+i.L CITY PARCEL St MAPN# OWNER'S NAMM 4 ADDRESS LJ—ZPHONE# CONTRACTOR ApL74IEB�G LICK 77�9•�3 PHONE/ f - SUB CONTRACTOR ADDRESS LIG# PHONE I TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MOMTORING WELL f ❑ OTHER _ © INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL! J New❑iwwalr H.P. 16 DEPTH PUMP 917_Fr. fnWT WATER LEVEL O HYPE OF PUMP] ❑,OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL it ❑ SOIL BORING B Cl DESTRUCTION. IYJYMDED USE JYPE OF WELL CONSTRUCTION SPECIFICATION! - A ❑ INDUSTRIAL ©OPEN BOTTOM DIA,OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMEBTICIPRiVATE ❑GRAVEL PACKIStZE TYPE OF CASINGMSTEEUPVC DIA,Of WELL CASING D ❑ PUSUCIMUMCIPAL ❑DRIVEN DEPTH dF GRbOUT SEAL SPECIfICAT10N It ❑ IRRIOATIdN1A6 C]OTHER GROUT SEAL ItMALLED BY GROUT BRAND NAME E ❑ MONITORING OIDUT SEAL PUMPED: ❑Y. ❑Ne CONCRETE PEDESTAL SY DF11LLER-❑Y.. 13N* S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE 3 PROPOSRRA CONSTRUCTIONIDRIWNG METHOD., MUD ROTARY AIR ROTARY AUGER CABLE OTHER !REBY CERTIFY THAT I HAVE PF�PARED THIS APPLICATION AND THAT THE WORT(WELL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AN[ :OULAT10H8 OP THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOUJOWING:'I CERTIFY THAT IN THE PERFOfV,M1ANCE OF THE WORK FOR WHtCR "- THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WOM MAN-19 C�OMPENOAT10N LAWS OF CAUFOFINIA-' CONT'RACTOR'S HIRING OR SGB-CONTRACTING SIGNATURE CERTIFIEI THE FOLLOWING; 'I CERTIFY THAT IN THE PERFORlaANCE OF.THE WORMS FOfl?v ICH-THIS PERMIT-IS-ISSUED,1-SHALL-EMPLOY PERSONS SUBJECT T6 WORKMAN'S COMPENIIATION LAWS 01 CALIFORNIA." THE APPLICANT MUST CALL 241WURS IN ADVANCE MR ALL REOUNW INSPECTIONS AT 120914011-3422. COMPLETE DRAWING AT LOWER AREA?ROrVIDED. �J "rood X ntt., ...__�. - MAT PLAN Mvorw to 800161 S906 'to T, NAMES OF STETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOGATWN OF HOUSE SEWAGE AL S SYSTEMS• RESYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,WANG OEMENSlONB AND NORTH bIRECTION. EXPANSION OF SEWAGE DISPOSAL 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. tOCATION OF WELLS WITHIN ING PFI PE ONE HUNDRED FFF•IY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PfIOPERiTY OR ADJOINING PROPERTY• - `. s. ,- f .. . 44 44 : :..:.:. .........>... ;. . . ........ ... .. ... ... _:... . °.... :.... ... .. . ;... 1,114-,1 s