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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 308, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-388 ////F (209) 4683420 (Pu� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPMATION 18 HIM BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WDIK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE IM H SAN JOAQUIN COUNTY DEVELOPMENT TRUE,CHAPTER 8-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY)PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRE6810R APNNI+�^ �nom/ �I)� ,/N.��/� /\ D CITY /V/�/Y / L�R PARCEL SIZEJAPNf p�,L �yJ OWNER'S NAME C/J C/T 1 el 4/ /V JET/ ADDRESS RHONE I /J CONTRACTOR /n/l/ ADDRESS /J /'/s��/1L 11CI_SfPHONE IF BUB CONTRACTOR �Ly( ADDRESS LIC# PHONE I Fi/ev' (, TYPEOFWELLMRIMR 5(NEWWELL ❑ REPLACEMENTWELL 13 MONITORING WELL0 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VA R EXTRACTION WELL I J Ne ❑RepYr H.P. DEPTH PUMP SET-163aFT. FIRST WATER LEVEL O (TYPE OF PUMR ❑ OUT-0FBERVICE WELL ❑ GEOPHYSICAL WELL♦ ❑ 801E BORING 8 ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ALDOMESTICIPPNVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEEL C DIA.OF WELL CASING D ❑ RIBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROAT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Ys ❑No CONCRETE PEDESTAL BY DRUM❑Ys ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S PROPDSED CONSTRUCTIONIDW WNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORE WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' I UCANT MUST CALL HOUR N)ADVAN' MR ALL R UIRFD INSPK AT 130814W41AM COMPLETE DRAWING AT LOWER AREA PROVIDED. Y Dew 61pny% L Tltle A/,9 . RAT RAN JD to SCelel 6wla 'to 1. NAMES OF STREETS OR GADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISMSAL SYSTEM OR PRO SED 3. OUTUNE OF THE PRDPEHTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. PAYMlEN' oca Nov 2 4 1998 SAN JOAOUIN CUUN iY \ PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVIS10,, — G -- _-_ DEPARTMENT USE ONLY ��'r AvpnuHun A—,tw BY Daw ar7JJ C Gtou Irepsllon BY DNS PUmP Irspstlen �ai,�, Drbuotion Ir�pectlon BY Dew Cemmmu: ACCOUNTING ONLY. AID, FACT PE COD" FEE INFO AMOUNT REMITTED CHEC (CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE 5 ' 6 S _5' r r i 3