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APPLICATION FOR WELLJPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 96201-388 (209) 468-3420 I C) S V(`L,/I f WwR UNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED llA 1 (Complete in Triplicate) APPLICA ION IS HERE BY MADE THE SN JOAQIN COUNTY FOR A MT TO NSTALL THE JOAQUIN COUNTY DEVELOPMENT OT TLE,CA AF U 705.3.Ad=&EZ�AN16�AF�F SAN JOAQUIN CTRUCT AND/ORIOUNTY PUBLIC HEEAALDTH ESC�VICDES.ENVIRONMENTALBE .THIS APPLICATION(HEALTH S MADE(DIVISION IANCE WITH SAN JOB ADDRESS/OR APNI z d _� 37 s-- [ CITY S PARCEL SIZE/APN# I /� OWNER'S NAME ADDRESS T o /�� ✓rYT /I(•-/�!)J20f1��/hONE r ��573 3 CONTRACTO-M&, �Gy �, �- ADDREkP=( '2 A .1TG,�/c—/[i.iP UC 13 PHONE 1jLj�- SUBCONTRACTOR ADDRESS UCS--PHONE# TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# �Cti V c ❑New QE�Repelr H.P.4LI)[Z DEPTH PUMP SE3/�FT. FIRST WATER LEVELj,,'1-9 D (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL 1 ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D I ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEELlPVC DIA.OF WELL CASING O V ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yee ElN. CONCRETE PEDESTAL BY DRILLFR:❑Yes ❑No 5 f APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S i PROPOSED CONSTRUCTION/DRIWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE AWS,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 WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATU E CERTIFIES V. THE FOLLOWING: I CERTIFY THAT IN THE PER MANCE THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEHf AT N LAWS OF CAUFO EAP CANT MUST CALL URS IN VANCE FOR ALL REOLARED INSPECTIONN&^&AT 1209)4aa3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. r Slpned X Title p�F.�S De[e PLOT PIAN(Drew to Sce)e)Sule 'to F 1. NAM S 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 5. 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, n SEP 1 3 1995 ,-AN JV.yf�lii,V 1., NU'BL1C HEALTH =N 'I131--)NME: NTAL r-iEF;LTH _ DEPARTMENT USE ONLY App iution Accepted By l ,n D//to Ar LL - �. - / /l it l' Jjj/j // T/ /