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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES PAYMENT ENARONMENTAL HEALTH DIVISION �CE��E� P.O. BOX 388, 304 EP^.T WEBER AVENUE, STOCKTON, CA 95201308 (209) 488.3420 APR 0 1 14oF SAN : :`.` pl;.l (; 1,114TY NON-REFUNRRRIF PERMIT EXPIRES t YEAR FROM DATE 1390ER PUBLIC Ht:A I ! 1N/'/IDES '7 (Complete In Triplicate) ENVIRONMCN I:.:!^: L7 pl'JISiON APPLICATION IB HERE BY MADE TO SAN JO N C NfYFOR•A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WOIK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE NTFII 8A! JOADUm COUNTY DEVELOPMENT TITLE,CHAPTER 8-1 l 3 AND THE STANDARDS OF RAN JOAQUIN COUNTY PUBLIC HEALTH RERVIOEB.ENVIRONMENTAL HEALTH DIVISION. JOB ADORESS CH,(q r _: 3514f -W, L97KrnA A� -+ _CRY PARCEL mZE/APNI 5% T !� TQ1.-rr�Q r7 OWNER'S NAME ,JAMF--IES r7L;L�-•Fx)' /�.y,J-FM GLQ6 �+L�AODIIESB 1-.O•I.30u LT�� f 4,1L_aZ 9•j PHONE�Z aq) p 3j-46��oi CONTRACTOR (1IIA9:r0jWLI -� ASSC` ADDRESS ala JN wLiY ZJCF PHONE 1 .— v 1 —j BUB CONTRACTOR /.IF'T . My— 95J3 ad ADOMIRS LLAJ•I{VVST[av Lam. . (ICI PONE/3t, 7CJ tom. ra. 4eL,da ZA Y.L'/tb TYPE OF WELL/PVMP. ❑ NFW WELL ❑ REPACEmew WELL ❑ MONITORING WELLa ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELLF J. RYPE OF PVMPI N,. ❑P40W 0 RN N.P. DEPTH PUMP SET_". FIRST WATER LEVEL (� ❑ OUT-OF-BERVICE WELL ❑ GEOPHYSICAL WELL I BOIL BORING a ❑DESTRUCTION: 1 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A; ❑ INDVSTRNL 13 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p ❑ DOMESTICTFVVATE ❑GRAVEL PACK/BIZE TYPE OF CAGING/STEED DIA.OF WELL CASINO pi 11PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL Ff/a.L- /7L�?/¢ SPECIFICATION R. ❑ IRIIICATIONIAQ ❑OT7-bµ HER GROUT SEAL INSTALLED BY GROUT BRAND NAME SAJS 447 : f E ❑ MONITORING 7 1*'-FTH5P GROUT SEAL PUMPED: ❑V. ❑Ne CONCRETE RAESTAL RY DRILLER:❑Y. [IN. 5 APPROX.DEPTH 14:2I �Jr (( '^ ,) III LOCKING CHESTER BO%/STOVE PPE S` POPOSID CONSTRUCTIONIDIVLLLNO METHOD: MUD ROTARY AIR ROTARY AUGER__CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOIK HALL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE lAWB,AND RULES AN REGULATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE"' M FOR WHIC4c 6 M THIS PERMIT 1SUED,1 SHALL NOT EMPLOY KMONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Of CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIEC THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE 11 NT MUST CA S IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12 14pOA22. COMPETE DRAWING AT LOWER AREA PROVIDED. X 7y // THI. D.I. lov MOT PAN IM.1.S .l Sul. STREETS OR RS le 1. NAMES OF OADNEAREST TO OR BOUNCING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE OI9PORAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, E%PANBION OF SEWAGE DISPOSAL SYSTEMS. B. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND IMPOSED a. LOCATOR OF WELLS WITHIN RADIUB OF ONE HUNDRED FIFTY IT. STRUCTURES,I(((NCLUDING COVERED AREAS SUCH/AS PATIOR,DRIVEWAYS, AND WAIAS. ON THE PROPERTY OR ADJOINING PIDPERTY. 91-q \\A9r _ 9 • \` • \�\ 9??O-O \gypo ,\ 171 ..,�+ry.� � �\, ..�..b.• m ry DEPARTMENT USE ONLY Appll t. Ape W Br D.a L14hk OreM Hnp.Gen By D.I. Pump In,v«nen BY Do. OSNuvnen InpMl.n Br AN D.I. 4 . Cemme nc l'UHUfHEALII-1 yl;r;I:I :H• ACCOUNTING ONLY: AID( FACT LPE CODFI FEE INFO AMOUNT REMITTED CHECK/ MH RECEIVED by DATE P9W11TUOEVICE REOUES T NUMRM INVOICE rL I- X-ff,