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APPLICATION FOR WELUPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADOnESS/On APNN/ �C/ (" CITY q —`-yPARCEL 912E/Ai'NJ OWNE R'9 NAME 11. /L/.LJ �r �rj-ZL� gB /�U �, • ( --1 PHONE! ^QG1/ \��r CONTRACTOR �'-J �'C!„ L-��.._y� C/ ADDRESS <�I UC!_/(, -13 3 PHONE SUS CONTRACTOR ADDRESS LIC, PHONE J TYPE OF WELL/PUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONRORING WELL J ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL J ,/ ❑New❑Flepdr N.P. T DEPTH PUMP SET1D FT, FIRST WATER LEVEL p/ O� (TYPE OF PVMPI ❑ OUT-OF-SERVK:E WELL ❑ GEOPHYSICAL WELL J ElSOIL BOIONG B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p ❑ DOME9TK:/T`RVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASING p, ❑ PUSLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRGAigN/AO 13 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME F (I\-- 0 v❑ MONITORING GnOUT SEAL PUMPED: ❑Yr ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yee ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE 5 PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE MATH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER On LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWRNO:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS BURJECT TO WORKMAN'/COMPLT/0AT10N LAWS OF CALIFORNIA.'(\7/�11/FJ//1PPUC ANT MUST CALL 24 HOURS (IIN�ADVANCE FOR ALL REGUIR'ED INSPEC�IT,I,ON�@ AT(20014004423. COMPLETE DRAWING AT LOWER AREA PROVIDED.Slo—d X i" Y \T-*it L. Titf. PLOT PLAN Sade)Sade 'to 1. NAMES OF STREETS OR ROADS NEAREST TO On BOUNDING TIIE PROPERTY. 4, LOCATION OF HOUSE SEWAGE D19FLTSAL SYSTEM On PnorosED 2. OUTLINE OF THE PROPERTY,OIVMJO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ]. DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTINO AND PROPOSED S. LOCATION OF WELLS WITHIN RADWS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOB,DRIVEWAYS,AND WALKS. ON THE PROPERTY On ADJOINING PROPERTY, ... :. i......:.....:....:.......... ...:. .......'. .. .... r..... i ....i. .... .. .. .....;....'• PAYMENT .. :....... JUN 3 0 1998 SAN .. (�TY SERVICES CNVIROB tv ENTALUUHEA HEALTH DIV sIOn, . ........ .... ..... _.. I� DEPAATMENT USE ONLY Applleetlon Aeeepted BY D 6 Grout I—P-0on BY is Puny I-peetlon BY e Dnelnctlen Impeallon flY Dete Commd�b: ACCOUNTING ONLY: AID/ FAC! PE CODES FEE INFO AMOUNT REMITTED CHECK! ASN RECEIVED BY DATE PERMIT/SERVICE REOUEST NUMBER INVOICE 3Q