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_ APPLICATION FOR WELLIPUMP PERMI" SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (209) 4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in TOPHObl APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PEFMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.ANIS IRON ENTATION IS MADE IN COMPLIANCE CE WITH 6M JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER y�//8/II-1115..3}'AND THE STANDARDS SAN JOAQUIN COUNTTYYjPUBl1C HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR AM' 'N —/ 442 � �; CITY�.+• '� ` PARCEL SIZEIAPNY OWNER'S NAME ems` ADDRESS ONE* CONTRACTOR , !O T— L ADDRESS CY �RIONE I y ADDRESS LIC* PHONEY SUB CONTRACTOR TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER �1 ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-0ONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J S q L}..� ❑N.DI�R 11 H.P. DEPTH PUMP BET/.32Y FIRST WATER LEVEL�� ffYPE OF PUMP( S ❑ DUT-0FWELL ❑ GEOPHYSICAL WELL ❑ SOIL8ONN0 r^ ❑DESTRUCTION: INTENDED USE TYPEOF WELL CONSTRUCTION 6PECIFICATION6 A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTICIPNVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEEUPVC DIA.OF WELL CASING D ❑ PUBLICNUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT REAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: 13 Y. ❑No CONCRETE PEDESTAL BY DNLLFB:❑Ya ONO S APPROX.DEPTH LOCKING CHESTER SOXJSTOVE RPE S PROPOSED CONSTRUCTIONRHSWNG METHOD: MUD ROTARY AIR VOTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WON(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WON(FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUS{ONTRACTING SIGNATU CERTIFIES THE FOLLOWIN ERTIFY THAT IN THE P RMA CE OF THE WONL FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSA N LAWS OF CAUFOBW TN TCA HOU'IN AD FOR ALL REQUIRED IN6PEp#IOyE AT I3Oel leeiA3i. COMPLETE DRAWING AT LOWER AREA PROVIDED. BIPn.e X Z T 9 D.te ROT PLAN IDI.W to S 1.)SMI. 'I. 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUNE 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 FIFTY FT. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. PAYMC-N SEP 13 1995 &AN J� I Li Us r,HEq(TH SERYIGI--;; EN F?ONRdENTAL'HEgIH. c DEPARTMENT USE ONLYBy ��/ bpn..non Aco.Pt.e � /n'�/G----�- F) // qN�k 1 I ),l 7 S Nw �. GH,tX Itip.c[ion B, D.I. Pump InpeOlion Br D Wtion Imp ljon BY p.Le c.mmenlr ACCOUNTING ONLY: AID# FAq R CODES FEE INFO AMOUNT REMITTED CHEC (CASH RECEIVED BY DATE PFMIITISERVICE REQUEST NUMBER INVOICE f k l(a FOa 9 n O,?