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APPLICATION FOR WELL/PUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NOWREFU!lDABLE PERMIT EXPIRES 1 YEAR FROM GATE ISSUED IComplet6 M TrIpRe6ta) APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOtt INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER X9.1 115.3 AND yTHE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMBION. JOB AOORE98A7 APHd >� �rt,/• V+'e nJT CITY tG.C: PARCEL 612E/APfJs OWNER'S NA 88 PHONE! f CONTRACTOR ADDRESS PHONE RUB CONTACTOR AbbfiE88 LIC .PHONE�N TYPE OF WIEL MP• ��{' t ..�� iCS.TIEW REL! [3 REPLACEMENT WELL ❑ MONITORING WERL• ❑ OTHER ❑ INSTALLATION ❑WELL STEM REPAIR ❑ CRO8S-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 0 � 1Naw❑Repalr H.P. T DEPTH PUMP SET j.AFT. FIRST WATER LEVEL 2 r O {TYPE OF PUMP! ❑ OUT-or-WRVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOM BORING e []DESTRUCTION: INTENDED UtE TYPE OF CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_ / DIA.OF CONDUCTOR CASINO g ❑ DOMESTICIPR IVATE I RGRAVEL PACKMIZE TYPE OF CASINGI8TEETJPVC i1 C– OFA.OF WELL CASING tt O lid PUBLK IMUMCIPAL ❑DRIVEN DEPTH OF GROUT SEAL— L-4ZQ _4k __ SPECIFICATION44cTD R ❑-IRROAT1oNIA0 ❑OTHER GROUT'SEAL INSTALLED BY �1�S�I I f 4, GROUT BRAND NAME F� E ❑ MOWTORHO GROUT DEAL PUMPED: IN Yw ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yr IsNe S APPPWX-DEPTH lJ F� LOCKING CHESTER BOX18rOVE PIPE S PROPOSED CONSTRUCTIONIORILT1110 METHOD: MUD ROTARY_��AM ROTARY AUGER CABLE OTHER I HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WALL.BE DONE IN ACCORDANCE WITH GAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COVNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWM.,'I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORIONAN'6 COMPINSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUE-CONTRACTING MONATURE CERTIFrEB ' THE FOLLOWING: .I CERTIFY THAT IN THE PEWORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORMAR'S COMPIE7YSATTON LAWS OF CAUFORMA.' T PPUCANT M02T CALL 24 HOURS IN ADVANCE FOR ALL REQUITED INSPECTIONS AT 12091480-2422- COMPLETE DRAWING AT LOWER AREA PROVIDED. 840nnd x TIIra Dote PLOT 1'U1N Ibrwv to SoatO 8aa1a 1. NAMES OF OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED I !. Ol1tlIHE OFT PROPERTY,GIVING WMENSION6 AND NORTH DIRECTION. EXPANMN OF SEWAGE DIBPOGAL SYSTEM6. 7. DIMENSIONED OVTLRNF.8 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RAOIU6 OF ONE HUNDRED FIFTY FI. STRUCTURES,INCLUDING COVERED AREAS SUCH A6 PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPEFTIY OR ADJO04M PROPERTY, X11 -Z HSS' �' �, ..... DEPARTMENT USE ONLY Aaplleotlen Aeeopted By Dole Area Grout Ir Pectten 9 Onto Prxnp Impeetlen By onto Oe Irgmtlen IrwpaNlen By Date Cemmerxa: s ACCOUNTING ONLY: AID# FAC# PE CODES FEE INTO AMOUNT REMITTEO CHECK/!CASH RECEIVED SY DATE Po"TIGERVICE REQUEST NUMBEII INVOICE - E i Pub Health Serv.-Enviro,173(1/97)