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APPLICATION'F0 WELLIPUMP PERMIT -SAN JOAOUIN COUNTY PUBLIC HEALTH SERVIL ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 904 EAST WEBER AVENUE, STOCKTON, CA 95241988 (209) 408.3420 NON-REFUNDABLE PERMIT EXPIRES't YEAR FROM DATE ISSUED IComphtn In T►IpRatnl APPLICATION TS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.11116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APNI � � -2 � v_ _s 7 1,/V ALJ` CITY_y��•�J PARCEL SIZEIAPNI O�� 40^� OWNER'S NAME L P, ADDRESS 10 I, F n � 2/4LNE I 'J CONTRACTOR C_C A IC��I 1~��-- ADDAES6 Z T F 'CAQ uc,32& PHONE• L/ SUS CONTRACTOR ADDRESS LICO PHONE/ TYPE OF WELLIPLIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL v ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL M ' J I ❑Now❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMPI ❑ OUT-OF-SERVICE PLL 13GEOPHYSICAL WELL If © SOIL BORING 8 RUCTION:/`J 202 2!/1 r()() 40 _94a -SYC Zt a '*f tom + e—) INTENDED UO TYPE OF WELL 1� CONSTRUCTION SPECIFICATIONS A j ❑ INDUSTRIAL ❑OPEN BOTTOM DM.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMESTICIPRIVATE 13 GRAVEL PACKISIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING '' '. D ❑ PUBuCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION ' R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yes [IN. CONCRETE PEDESTAL BY DRILLER:❑Yes ❑Ne S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE Sn PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER -` 114CREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND(+-i 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 POR WHIC THIS PERMIT IS ISSUED,E S LL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'•COMPENSATION LAWS OF CALIFORNIA,' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOYNNG: CE IFY T T INjHj PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF� ' BALIFFORNI ' AN M • C M 8 IN ADVANCE FOR ALL REQUIRED pECTI� 120014"-3422.��OMPLETE DRAWING AT LOWER AREA PROVI ED IIJJ� O+ta PLOT PLAN(Draw to Seas?Scala "to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL BYSTEM 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 FIFTY Fr, STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, m .,.., v - - b v� . . t... - . . . . nn. jULIA 1996 PUBLIC HEAI_T , SERVICE_`:: ENV'E�G�P CN�4L HEAL71� �Ir'I� 0. t '-ro.•-a�.�_�.+ � --�="`� �. -- �� DEPARTNIEIVT'U5E ONLY - Application Accepted By Date Grout Inspection By A 44 Date Pump Inspection BY �ry Dale Destruction Inspeetlen By. Data ! � - Comments: /P.dO 12 A Nil 2.14" 04CI4 dofe 1 6 ACCOUNTING ONLY: AID# FACN k PE CODES FEE INFO AMOUNT REMITTED CHEC AS RECEIVED BY. DATE PERMITMERVICE REQUEST Numm INVOICE 0 3��