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APPLICATION FOR WELLIPUMP PERMIT �R.P SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAOUIN ST., STOCKTON, CA 96201388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (ComPlEle in Triplicate) APPUCATK)N IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOR(DESCRIBED.THIS AP ATION 15 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT''TRILL,CHAPTER 9-1115.3 AND THE STANDARDS SAN SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADORESSIOR/AJM# 2 ( �z 44Q,4 —a' Q CRY ��f - PARCEL SIZUAPNI ONMER'S NAME.AAL✓'4d D� �,f LJFD'T"" ADDRESS NF CONTRACTOR YIL G.T.(A �dQ �J i ADDRESS r IL CI RONEI y SUB CONTRACTOR ADDRESS UCI MORE I TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECTREPAIR 11 VAPOR EXTRACTION WELL I ✓ Sp) ❑New Lalli .k H P. DEFT"RUMP SET, JyFf. FIRST WATER LEVEL �2 O I\ (TYPE OF PIMP) �`/ V ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOS BORING B (n ❑DESTRUCTION: V 1 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS p ` ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ OOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CRSINGISTEEIJPVC DIA.OF WELL CASING O ❑ PUBUCIMUNICIPAL ❑DRIVER DEPTH OF GROUT SEAL SPECIFICATION S - ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E r ❑ MONITORING GROUT SFAL PUMPED: ❑Ys [IN. CONCRFTEPEDESTALBYDRLLFR:❑Yr ON. 5 APAOX.DEPTH LOCKING CHESTER BOXISTOVE RPE 5 (� PROPOSED CONETILIIC110NRMIIWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PWPARFD THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. ROME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 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 CAUMMA.' CONTRACTOR'S HIRING OR SIIB{ONTRACTING SIGNATU CERTIFIES THE FOLLOWIN ERT THAT IN THE RFOPAAA E OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPFNBA N LAWS OF CALIFO THE CANT MWT/C/A/{/1��P�NO RN ADVANCE fOn ALL nEOURF➢INSV/F/�I/q/HI�B/AJT 1]081 t8BJE38. COMPETE DRAWING AT LOWER MEA PNOVIpEp. BbMJ>� /�/ca _ TIHe�7 r�� Dere ROT PAN 0—Io Sinal Scale 'le 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE ENSMSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTYFT STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. �e w LAe IA GI I � s'rr6"t'kd1�CVl�« SEP 13 1995 NUF3UE �+E n�: -