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APPLICATION'EOil WELLIPUMP PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SERVICE ENVIRONMENTAL HEALTH DIVISION P.O, BOX 388,304 EAST WEBER AVENUE, STOCKTON. CA 95201388 (2119) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompkh In T►IpReaw APPLICATION 18 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOW DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCEWTI If SAN JOADUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB AbbliEs9lOR APN! CCTV /1 PARCEL SIZFJAPNI OWNER'S NAME_-- 1 GK G(�e W Q�._ ADDRESS SII H Q y PHONE CONTRACTORVQTLiRD C, �nytltnflM4� t n[ ADnaEsslS4 w. M ( '� ucM_b$OLZ�I rHorlE !t)9-f$,b Otb,� 1 f )• 1 . i. SUB CONTRACTO - • • •r AbORE8131 '"*I17 •. LICI Z 2 7 PHONE i1<�yYib TYPE OF WELL"MP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL• ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL• ❑New©Repel, H.P. DEPTH PUMP SET ITYPE OF PUMPI FT. FIRST WATER LEVEL O ❑ OUT-0vSERVICE WELL ❑ GEOPHYSICAL WELL N 4DL SOIL BORING a ❑DESTRUCTION: INTENDED USE TYPE OF WELL, CONSTRUCTION SPECIFICATIONS q A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION._I 5 DIA.OF CONDUCTOR CASINO SN p 11DOMESTICIPRIVATE ©GRAVEL PACK)91ZE TYPE OF CASINGlBTEELIPVC_[V DIA.OF WELL CASING�Fr b 11PVSLICAUUNICIPAL KDILIVEN DEPTH OF GROUTSEAL 'y 1 SPECIFICATION_N14 a ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY TPB�1 f m;E GROUT BRAND NAME LV E4 1011 e��_�D E e R MONITORING ORbUT SEAL PUMPED!4- y Ne CONCRETE PEDESTAL BY DRILLER;®Yee ❑Ne 5 APPROX.X.DEPTH .4 Z A LOCKING CHESTER SOXISTOVE PIPES PROPOSED CONSTRUCTlONlML1WN0 METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER. Geo .PRob c 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAGUIN COUNTY ORDINANCES,Wr ATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOLARED INSPECTIONS AT 120014604122. COMPLETE DRAWING AT LOWER AREA PRbVIOFO, Slpned X Tltls_A�p- (S�.61 j t _bNa z -92 Ll v RIOT PLAN ID.ew to Bealel Soale 'to 1. NAMES OF STREETS OR ROAOS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTUNF.B AND LOCATION OF ALL EXISTING AND PROPOSED E. 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 :. � a VV oq K f1 . I DEPARTMENT USE ONLY AppBcatten Aeeepted By Data Mw Omot hnpeotlon By bete Pump Inapectten By pate Oeet,twlen twpectlen By Date Comment►: C jj C1 A11111n, I/ ACCOUNTING ONLY: AID/ FAC/ PE CODES FTE INFO AMOUNT REMITTED CH !CASH RECEIVED BY DATE PVWIT)SEHVICE REQUEST NUMBER INVOICE f 4�s S D Z-VQQ Pub.HeaRh Serv.-EnvirD.173(3196)