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APPLICATION FOR WELLIPUMP PERM' SAN JOAQUIN COUNTY PUBLIC HEALTH SE1rm8ES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Y 2 (Complala In TRIpIic6t6) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WRIT SAF JOAQUIN COUNTY DEVELOPMENT/TITLE,CHAPTER 9-111�1f5.3 AND THE THE STANDAAR�DS OF SAN JOAQUIN COUNTY PUBLICO HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNI //// 1�'�46/ �' /'r ✓' .' ltl IW CIT�YJ n [+->,fI�-./VAS 57� PARCEL SIZE/APN/ (� OWNER'S NAME X)/p-/zj L/.S/J N/y,( ADDRESS / U-190X Ifl l/B C,/1i?. 5�0;71_p PHONE• CONTRACTOR r0S_PJ Y�nll�7 ADDRESS �J 4al //0//)'//�O LIC/ �-Sfl PHONE SUBCONTRACTOR ADDRESS /'a C;/ ( �'J, 1. �7�G LICE PHONES TYPE OF WELVPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORINO WELL E TT+ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL E J C h �T''N.❑Rao.1, H.P. DEPTH PUMP BET FT. FIRST WATER LEVEL /,X O (TYPE OF PUMPI ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL E ❑ BOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O ❑ DOMEBTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASING/STEELTVC DIA.OF WELL CASING 0 ❑ PUBLICWUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PIMPED: ❑Yr [IN. CONCRETE PEDESTAL BY DRILLERS❑Y— [IN. 5 APPROX.DOTH LOCKING CHESTER BOX/STOVE PPE S( PROPOSED CONATRLICTIONIDIULUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AM REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WOR0(MAN'6 COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIER THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OI CALIFORNIA.- THIS,PPLICANT MU i CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED IN//6�� IP PSCONB W AT(2 )/YJA22. COMPLETE DRAWING AT LOWER AREA PROVIDED. sloo.e X //////✓.1/©- i�� TDI. U Z'64y D.t. PLOT PAN (Drµto SoW.l Sw1. 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. T. DIMENSIONED OUTUNFS 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. I IN �, tal cd MAY 2 2 1996 SA,v dw , ENV/PONM 7q Cri L R�CfS n) v1, 'Op _ I DEPARTMENT USE ONLY /_ 1` 1(,., APPIIo.tlon Aae.Plarl By U.I. 1C/ 'T'o4. 1 Grout Lroaetion By Dirt. Pump InNP.•tlon By mu -19-910 Dsvwtlon ImorroSon By D.I. Comment.: ACCOUNTING ONLY: AIDP FACE PE CODES FEE INFO AMOUNT REMITTEDEC CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE Q D # l 94U, 3a1`i