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Ld APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (CBmplel�M TtiPNntEI APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOW bfSCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH bMSION, JOB ADORESS/OR APN! &)S S [T0LAQ$y' S4_f_ CITY J `=t� � PARCEL BIZEIAPN/ OWNEA'S NAME-- f�`�--'—kV' ��' � ��Lt1n ADDRESS.[.U( S'y Ik. A yr tSt " - PHONE'/ 4 '��-L_� CONTRACTOR rY�-(— skS ockCr.�S ADDRESS `ft LCI �1"'PC11+r", M LIC/ r Q� -PHONEX15 !r �G•Zl BUB CONTRACTOR "�' 4+hy r ADDRESS 371 Jfl��l 1 C�' � LIc, G a3 8�PHONE i•T"-hZ'33-7I TYPE OF WEU PUMFp ❑ NEW WELL ❑ REPLACEMENT WELL © MONITORING WELL I ❑ OTHER © 1NBTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑New❑Roost, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL P .� BOIL BORING v S ❑bfGTRUCTI0N: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS tl -' A © INDUSTRIAL ❑OPEN BOTTOM OIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CABIN, ,r"'�V 7 p © DOMESTICIPRIVATE ❑ORAVEL PACKISIZE TYPE OF CASINGISTEE ______ LJPVC DIA.OF WELL CASINO kJ``A� A � O C3PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAU 15% . SPECIFICATION �j I ❑-IMOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY TewRi-%- GROUT BRAND NAME t�.. �- E j I MONITORING �p OROUT SEAL PUMPED: ©Yw a CONCRETE PEDESTAL BY DRILLER:�❑_Yes Ly Ne S APPROX.DEPTH t5 1 - -� LOCKING CHESTER BOXISTOVE PIPE qy S PROPOSED CONSTRUCTIONIDRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO SEGULATIONS OF THE SAN JOAOUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWNGI'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS tSSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA," CONTRACTOR'S HIRINO OR SUB-CONTRACTWO SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH T1410 PEIINI1 10 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUm®MsPECTNINt AT 1"014004422. COMPLETE DRAWING AT LOWER AREA PROVIDED, Slprmi X Y.V-t^�.�T T Tlge ��[,C/1'l.C_/�/,_ %Z/ieu Det.: _ UU PLOT PLAN Mrew to Selly Styli "to 1. NAMES OF STREETS OR TOADS NEAREST TO OR BOUNDING THE PROPERTY:, _ _ 4. LOCATION OF ROUSE SEWAGE DISPOBAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. -^ -m EXPANSION OF BEWARE DISPOSAL SYSTEMS, 2. DIMENSIONED OUTUNF,e AND LOCATION OF ALL EXMTNG AND PROPOSED E. LOCATION OF WFL.LB WITHIN RADIUS OF ONE,HUNDRED FIFTY FT, STRUCTURES,INCLUDING COVERED AREAS SUCH All PATIOS,DRtVEWAYB,AND WALK& _- -ro- ON THE PROPERTY OR ADJOINING PROPERTY. n o Z ' �Y 211 .X a N i w r _ h :4 �• o 0 3 0 4� g g u • I DEPARTMENT USE ONLY ApoBefllon Aeeoz 1,y r� Dot*. - �-'r Are* of"Impeallen By Otto Rfnp ImpeetIon By Dote OmIructlon Impevl BY Dote � T L "Oil Cemmentr. t _ ✓ NiI 40 0 �T ACCORNTINO ONLY: v I AJOP FACT 9E CODES FEE INFO AMOUNT REMITTED CHECK/!CASH RECEIVE BY DATE PBINIT/SERVICt REQUEST NUmmEn INVOICE 3S??I `I,eA If SR 00 22 33, Pub Health 5erv.-Enviro.173(1197)