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t APPLICATION POR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH BE S E-- �� ENVIRONMENTAL HEALTH DIVISION `"=r/ c � P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201 F6 2 31996 (209) 488-3420 NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH ICBmpIBtB In Triplieats) PERMIT/SERVICES APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-11115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORESSAIR APN! c `� // I_ Yl c.-F CITY ''gip IL�T/gYY�[I�-j/ �� [� PARCEL SIZE/APN! OWNER'S NAME V F (404e, XL _ gppRE88 tIV I'7,� �4LYJPd,ajA N PHONE,I� ? t CONTRACTOR ADDRESS , BA T T rte/—„,��{{{ uC! PH�O E!� 4�`BIWMNFIM,B1lR l ,iR�� ADDREB8 '• C' '�/T L% U I�' --ppOHE0 TYPE OF WEUJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ^'�\—�”-❑�OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL! J ❑New❑Repelt H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL O (TYPE OF PIMP ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL! BOIL BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS1 A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION /J DIA.OF CONDUCTOR CAGING p ❑ DOMESTKUPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEUPVCC DIA.OF WELL CASINO O ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL c1� ' SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED SY_�F A}Q'r"l,il GROUT BRAND NAME E ❑ MONITORING '^ ((�� GROUT SEAL PIIMPLD: ❑Ys ❑No CONCRETE PEDESTAL BY DRILLER:❑Ya [IN. 5 APPROX.DEPTH It_/,ypy LOCKING CHESTER BOX/STOVE RPE \ S PROPOSED CONSTRUCAON UJN METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1�1 I HERESY CERTIFY THAT i HAVE PREPARED THIS APPLICATION AND THAT THE MRK 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 WOR(FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMM$ATION LAWS OF CALIFORNIA.' THE APPIICAI MUS ALL 24 IIDIBRS IN ADVANCE FOR ALL REQUIRED IN Tg'NBA,T 12081488.8423. COMPLETE DRAWING AT LOWER AREA PROVIDED. 9 Sj're x-1 Tltle�'7�J��J�(J)( PLOT PLAN IDr.w to Swl.l Style 'I/ I. 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NOUN 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. ....•......... ....1 p& p. o: to ',� �s c . . �1Z DEPARTMENT USE ONLY / APpllc.tion Accepted By K O1 Date RG Ara GrpVtlrnpecuen By. Det. l Wmp impaction By Dene Datrwtlan Imp«Oen By O.te JIL Cpmmenb: ACCOUNTING ONLY: AID! FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/:ASH RECEIVED BY DATE PERRITISERVICE REQUEST NUMBER INVOICE a061s5 `7n l0 00