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APPLICATIO .FOR WELLIPUMP PERMIT o fl q- SAN JOAQUIN f y PUBLIC-HEALTH SERVICES "i v,a ENVIRONL,-.iiAL HEALTH DIVISION P 0 BOX 388,446 N.SAN JOAOUIN ST.,STOCXTON,CA 95201-388 ' (209)468.3420 " I NON•REFUNDARLf PERMIT EXPIRES 1 YEAR FROM DATE ISSUED LN'IS ICompht&in Tr(pDut&)HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRACT AND/OR INSTALL THE WORK DESCRIBED-THIS APPLICATION 18 MADE IN COMPLIANCE WITH BAN I JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ADORESSIOR APNr 741 N- D trinh RrCITY RCPAEL SIMAPw FB YNER'SNAME James DeMartini ADDRESR,O. Sox 431 Linden PHONE coNTRAcToR Purviance Drillers Inc, ADDRESS P.0-Dox 64 Lindeac.377923 PHONEr$$7-3554 F"CONTRACTOR ' ADDRESS LKr PHONEr �..PE OF WELLAPUMP; I NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL• ❑OTHER , 13 INSTALLATION [I WELL SYSTEM REPAIR D CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL rSub ,f IPE OF FUMPF A NaY 13H-P•��' DEPTH PUMP GET —U-aT, FIRST WATER LEVEL O r ❑OUT-0FSERVICE WELL ❑GEOPHYSICAL WELL r ❑ SoIL BORING r . U DESTRUCTIOPP INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION& A- INDUSTRAL ©OPEN BOTTOM DIA OF WELL EXCAVAi10N�210 DL&OF CONDUCTOR CASING D_-:3 t DOMESgCIWtlVATE ❑GRAVEL PACKma TYPE OF CASINGJS UIPVC DIA.OF WELL CASINO_ 6 V A , D: � U PIJDLICIMUMCMAL ❑COVEN DEPTH OF GROUT SEAL SPECRFICATION A— ❑IRRILATIONJAG 11 OTHER GROUT SEAL INSTALLED BY PDT GROUT BRAND NAME E "ITONGSEAL.PUMPED:E[Yes ❑Ne CONCRETEPEDESTALBYDRILLER:❑Yw ❑NeFl:X.DEPT. LOCKING CHESTER BOXJSTOVE PIPE s , APOSED CON&TRUCTTON/DPoLIfNG METHOD:MVO ROTAIRY XX ADI ROTARY AUGER CABLE OTHFA _ I HEREBY CERTIFYTHAT I HAVE PREPARED THIS APPLICATR)H AND THAT THE WQRK WILL BE DDHE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,ANG RULES —AMC,(-' GUAIONOF T/IE SAN JOAQUW COUNTY,HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOL-OWIIM:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHIC-_ 116 f4RMIT 78 R88UfU,I SHALL NOT EMPLOY PERSONS SUB.IECT TO WORKMAN,#COMPENSATION LAWS OF CAUFORIGA•"CONTRACTOR'.N11pN0 OR SVBLONTRACTING SIGNATURE CERTIgEB� 1E FOLLOWING: "I CERTIFY THAT II THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN,#COMPEN&ATION LAWS OF+� . -:FVLFfO APPLCAN U. 24 HOLEM IN ADVANCE FOR ALL REQUIRED INSPIR:TNINp AT wn)4094U 7.COMPLETE DRAWING AT LOWER AREA PROVIDED. C, . pre no--L=.ip.2Late SPcTPtary _ D.R. PLOT PLAN Ml—"Se"$11, "Ie NAMES OF STT�ETS OR ROAD.NTJIREBT TO OR SOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED I OUTLINE OF THE PROPERTY,GIVING DLWNMONS AND NORTH DIRECTION. - EXPANSION OF SEWAGE DISPOSAL SYLTTEM& S-DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS VYITHIN RADIUS OF ONE HUNDRED FIFTY FT, STRICTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DNVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY• .... .._- ... ..,._.... ....... ... .. 1y -- --, .... ... ...... ...... .i_. ... - :...,. y... .............. D .... r" : ............ l 11 3 .... - c I ^I #�sE Puel_I H L r+vsrl�- 77 DEPARTMENT USE ONLY C� ..- I._PVnwtlen A—pW `� Arr 1 /� G—A hnps.en Sy — D.I..-7—I y'`1 Z r— 7 7 Dm 1 1 ir, . P nepectlan BY �0 y } eltrl,ceon InepecllPll By - �1 Om aRlmmh: ! 1 ACCOUNTING ON Y: AIOr FAGr PE COD[& F INFD AMOUNT REMITTED C MASH RECEIVED BY DATE ISERVICE REGLw4x NUMBER INVOICE o I I