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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 P"—"'69 klelge't"I NOR•REFURDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (campifu M TrlpUeata) APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WIt H SAN JOAOUIN COUNTY DEVELOPM EN /T TIT�LEE..CHAPTER 9.1 116 3/A/ulh� E SCAN RD8 F SAN JOAQUIN COUNTY PUBLIC H FLTH SERVICER.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APNf�]7 7 t/ L� - _ _CITY cf e PARCEL 812E1APN1 E Ilr OWNER'S NAME ADORESH r� /�J s PHONEf CONTRACTOR ADDITES■t T/ LIC/3�20 YDS PHONE SUB CONTRACTOR ADDRESS LIC/ PHONE f TYPE OF WELLMUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONNTOmNO WELL/ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL f J ❑Now 4Repd1 H.P. I DEPTH PUMP BET ,&FT. FIRST WATER LEVEL rTYPE OF PUMPI ❑ OUT•OF-SERVICE WELL ❑ GEOPHYSICAL WELL f ❑ SOIL BORING a ❑DESTRUCTION: INTENDED USE TYPE OF W CONSTRl1CTIDIi SPECIFICATIONS ''L ❑ INCUBTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p liOOMESTK'1PRIVATE ❑GRAVEL PACK/912E TYPE OF CASINOISTEEL/PVC DIA.OF WELL CASINO D ❑ PUSUCAAUMCIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRIVGATIONJAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME ❑ MOMTORINO GROUT DEAL PUMPED: ❑Yep ❑No CONCRETE PEDESTAL BY DRILLER:❑Yw ❑Ne s l \.. APPROX.DEPTH r� LOCKING CHESTER BOX/STOVE POPE S PROPOaED CONSTRUCTIONIORILIJNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HE9EBY CERTFY THAT 114AVE PREPARED THIS APPLICATION AND THAT THE WORK MALL BE DONE IN ACCORDANCE WITH SAN 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 MR WHICH THIS PERMIT IS ISSUED.1 S4NALL NOT EMPLOY PER@ON JEGT WORKMAN'S COMPENSATWN LAWS OF CAUFOWJL' CONTRACTOR'S HIRING OR SUB{ONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFO E OF HE WORK FOR WHICH THIS PERMIT M ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORSIMAN'S COMPETI AHHON LAWS OF CALIFORNIA.' T NT MUS�CALL241 IMA INCE FOR ALL REOUME77 FNaPECriDN!AT 12001440-5422. COMPLETE OMV511NG AT LOWER AREA PRQVIDED. 8lpnad X TIlla '�� Dote PLOT PLAN Mrew to Sada{Saele 'to 1. NAME@ Of BTF SETS OR ROADS NEAREST TO OR BOUNDOM THE PROPERTY, t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 7. OLITLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SfWAOE DISPOSAL SYaTEMS. S. DIAENSOONED OUTUWF.B AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADWS OF ONE HUNDRED FIFTY FT. aTRLICTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND W S, ON THE PERTY OR ADJOINING PROPERTY. j/ u PAY0,17EM ia. oag DEC 31988 ;al�,;o,ac;lulN Cvufu3-v / PU[iUC KEALTN SERVIICC,ES 1 , DEPARTMENT WE ONLY � � V ApPNeellen AaaePtad By C Dale LJ`J M� Maut kNpeallan By Dete M—P Impealian By Daetnrellan Iropeetlun RY Oeu Cammenl�: ACCOUNTING ONLY: MOO FAC# PE CODES FEE INFO AMOUNT REMITTED CH ABH RECEIVED NY DATE FEIMT149TVICE REQUEST NU NEER INVOICE r b c� 0-oo �15�5 3 Ol7