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'/ q APPLICATION FOR WELLIPUMP PERM' 00 7 s's/ SAN JOAOUIN COUNTY PUBLIC HEALTH SL, ICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201588 (209) 4683410 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete APPLICATION IB HERE BV MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUI CONSTRUCT INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAF, JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 8-111$.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSMA APNNII Z L7 F2F7i jA/LT 2 Q CITY (Lnk TAaR 11 P PARCEL SIZEIAPNI �/ OWNER'S NAME J LFz- A10 Mme`- Co ADDRESS Cn xn, yS3 PHONE y� CONTRACTOR JSJC > 1 Y j'9 ADDRE66 �yL'17J G FJ--Ail Y / TIi.r tl VT PHONE 1_9 V. --�R17 SUBCONTRACTOR S T,k-- y fur ADDRESS ❑C' PHONE!- TYPE OF WELL/PVMP: ❑ NEW WELL ❑ RERACEMENi WELL ❑ MONITORING WELL IF 1:1 OTHER !S13 INSTALLATION WELL SYSTEM REPAIR ❑ CROSS-CONNECTTREPAIR VAPOR EXTRACTION WELL K ❑ DEPTH RMP SETTYPE OF vFIRST WATERLEVEL J p ztp(y-�^ y..l,A✓ ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING 8 ❑DESTRUCTION:_ INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION{ �❑ IND RIAL ❑OPEN BOT-M, DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CAGING p W DOMESTICIPRVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/6TEELIPVC DIA.OF WELL CASING p ❑ RBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yr ❑Ne CONCRETE PEDESTAL BY DRILLER-❑Vee ❑Ne 5 APPROX. DEPTH LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONETI LICTIONIMULING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER MERIiBV CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES. STATE LAWS,AND RULES AHC REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WNICE THIS PERMIT IS ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPETIEATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.' APPUCAMT M/U�ST CALL M NOHOU�R{IN/}OVANCE FOR ALL REQUIRED IN,Ef/F/�JTI�O�Ni/S./,AT IZOiI tM il2]. COMPLETE DRAWING AT LOWER AREA PROVIDED. / Tltle ROT PIAN IDre to Soelel Goal@ to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 3. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROMSED S. LOCATION OF WELLS WYTHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH A6 PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. / V U 1� E I Ni E 'USLIC HEALTH S OVICF' - ]� to CLO _NVLRONMIENTAL HEALTH 01',i+SrC. etc, F DEPARTMENT USE ONLY APP11ce11—Accepted BY '��—"�' Dela ` \ Aree Grout Irnpeetlon BY eta Pump Inepectlon BY DNa 4 !3(57 DstrVcII.n Ivp@mlun By Det. Commenu ACCOUNTING ONLY: AID' FAG PE CODES FEE INFO AMOUNT REMITTED NEC ICAEH RECEIVED BY DATE PERMITISEAVICE REQUEST NUMBER INVOICE O �i J C� o33a1�