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APPLICATION FOR WELLJPUMP PERMIT $ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED r fk (C@mp111s In Tf$Rea111 APPLICATION IS HERE BY MADE TO THE SAH JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WORK DESCRIBED.THIS APPLICATION Is MADE IN CII IPLIANCE:Wrfl!SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTERe- 116.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY -1PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DfVLS1�N. _ JOB ADDRESSOR APNI 1 L I UJ e + CtfY S44 piyj i PARCEL 847HAPN!el - OWNER'S NAME L r s �`L x �6 + S T'JG�- a7 4 PHONE f CONTRACTOR /f 3So i`�/71'Mr P<+r �i• .. J )� �eoSC, ADDRESS YA<, ] 1 bb tff SCIS CONTRACTOR 'd' �.` ` 1 /� AOOTTE88��'',[�a iL J I� Uj�' 7.___ UC&�;2Q 44 PHONE#7a7'--5'7 i-'Y•++ �r ~ TYPE OF WELLIFU� ❑ NEW WELL ❑ REPLACEMENT WELL 19 MONIfORINQ WELL I - ❑ OTHER �• ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 0 J ❑Naw❑Reoak �. H,P. - DEPTH PUMP SET FT, FIRST WATER LEVEL O r. Ii YPE OF PVMPI - ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING R ❑DESTRUCTION; i INTENDED USE TYPE OF WELL. CONSTRUCTION SPECIFICATIONS A i ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION I A. 4eS' DIA.OF CONDVCTOR CASINQ D ❑ DOMESTKIMVA7E 19 GRAVEL PACKISZF TYPE OF CASINOISTEEUPVC P 1�7cz— DIA.OF WELL CASINO Z � r O ❑ PUBI ICIMUNICIPAL ❑DmVEN DEPTH OF GROUT SEAL c—P._ SPECIFICATION R 0 MMOATIONlAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E lC! MONITORING GROUT SEAL PUMPED: [1Y. ❑No CONCRETE PEDESTAL SY DRILLER:❑Yee ❑No S APPROX.DEPTH 2 0 LOCKWO CHESTER BOXISTO APE &'3C S 4 PROPOSED CONITTIUCTIGNIDAILUNG METHOD: MUD ROTARY AIR ROTARY AUGER„CABLE OTHER I HMBY CERTIFY THAT 1 IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE VAT"SAN JOA13UIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS 111"0,1 811ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-$COMPENSATION LAWS OF CALIFORMA.- CONTRACTOR'S HIRING OR BUBCONTRACTINO SIGNATURE CERTIF1E8 THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMrr IB ISSUED,i SHALL EMPLOY PERSON@ SUBJECT TO WORIGNAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APP'UCANT MUST CALL 4 URS IN ADVANCE FOR ALL REOVIA90 iNSPECTMNS AT 12081 4tl44". COMPLETE DRAWING AT LOWER AREA PROM PLOT PLAN IOtow to 8e.1a1 State lid 1. NAMES Of STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.GTVM OfMEMMONS AND NORTH DIRECTION. EXPANSION OF SEWAGE 00SPOBAL SYSTEMS. 3. DIMENSIONED OUTUNFA AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS BLICH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. tit®Fax � at w'_q , A Pas - x Note 767 pagges� F % rDm To Co./Dept. Co. Phone#p p0 � Phone# Fax If . 111 . - " Fax# i DEPARTMENT USE ONLY I Ayglla.tlen Aooep N. ' % % / V DoH LJ Maa. 51 iZVI 01-AIn.pectlm BY - Oale Pump In.Reetlen 9y OH. i i. D.ta Oa.lneelen 1n.Peotbn y Cen+rne�N.• ACCOUNTING ONLY! AID# FACT PE CODES FEE INFO AMOUNT RONYTED CHECK#!CASH RCB 'f DATE PERM TISEFMCE REQUEST NUMBER INVOICE �r�l - U a oZ �-