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• APPLICATION FOR WELLIPUMP PERMIT • O N SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 FILE C 0 P (209) 468.3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM BATE ISSUED (Campine In TrlpReata) APPUCATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WOFK DESCRIBED.THIS APPLICATION IS MAGE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-11}1(5.3 AND THE STANOARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH�SERRVICES.ENVIFIONMENTAL HEALTH DIVISION. JOB ADDRESSOR AP/N�yJ,(t��I`�C�I'��) ��'V.�J�'-//_� �C�V {M 1 �'t(/ I Z!o T� w' I IL{h,(J L �y1PARCEL 82E/ARII I 4� OWNER'S NAME J� -'^^""11�t I '^�'�S4f�l / � /2'� ADDRESS ZI• NO V CONTRACTOR ADDRESS Re1 P� C� ucs $3RgNE I?1F3�Sgss , SUBCONTRACTOR 5 _.'(+v"L.t'VI 'X (�l�`�� {7 L,/1 ADDRESS 5tl;c K-tC�1N� , �G uc,! 5I `�RIDNEv 4EJ'g71 TYPE OF WELL/Pump: 1:1 NEW WELL ❑ REF CEMENT WELL co ,-. MONITORING WFLL a Ka' L ❑ OTHER ❑ INSTALLATION Cl WELL SYSTEM REPAIR Cl CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL t ,/ ❑Nw ❑pl .Ir H.P. DEPTH PIMP SET_FT. RRBT WATER LEVEL O RYPE OF PIMP) Cl OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL 0 ❑ BOIL BORING g DESTRUCTION: 1 NTEMOED USE TYPE OF WELL CONSTRUCTION SPECIFICATION{ ({ A !J INDUSTRIAL 11OPEN BOTTOM DIA.OF WELL EXCAVATION I I HS A J r OIA.OF CONDUCTOR CAWNG 0 (� OOMESTIC/ROVATE LL MR,%VTL PACx/8RE NC , TYPE OF CASINGISTE,.&4-ll SGL'LCQLjf_+C DIA.OF WELL CASINO 0 '.� PUBUC/MUMICIPAL ❑DRIVEN tY 01 ho J DEPTH OF GROUT SEAL 0-40'/ by S SPECIFICATION / R i7 IRRIGATION/AO Cl OTHER 5a"A Y II`LCC GROUT SEAL INSTALLED BY PCG l V II Yll mm VT BRAND NAME N'El 41- 1•H 2"-r E r. L8 MONITORING - PGI 04- GROUT SEAL PUMPED: ®Y. 13N. �L CONCRETE PEDESTALBY DRILLER: Y. CIN. S 'I Mvmox.DEPTH 7 / bG]`l LOCXING CHEBTEA BO%/STOVE FIFE FT�p'[� (;CLI Ct1wLplCi7&'-' s MOMSED CONSTRUCTIONIDPIWNG METHOD: MUD ROTARY AIR ROTARY AUGER� CABLE OTHER HEREBY CERTIFY THAT I HAVE PREPARED TH18 APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND +EGUTATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES TME FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH H18 PERMIT IB ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN't COMPENSATION LAWS OF CAUFOR NIA.- CONTRACTOR'S HIRING OR BVBLONTHACTiND SIGNATURE CERTIFIES THE FOLLOWING: .I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT M ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' THI',EI AAPPICAANT MUST CAM 24 HOUt11 IN ADVANCE FOR ALL REQUIRED 11049 S TIOFCSAT 1(2`W �410* 21. COMPLETE DRAWING AT LOWER AREA PROVIDEO. V1II �I Bl'm X "�+ 4L--/ TISS POT PAN ID'..v m S,I W.I 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. t. LOCATION OF{OUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUNE OF THE PROPERTY,GING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SY8TEM8. T. DIMENSIONED OIJTUNES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN MOMS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE P OPEICITY OR ADJOINING PROPERTY. DEPARTMENT USE ONLY (Xy APPlk.tlen Aggted BY DKB Mq O "' G'P trS, etlen BY D.t. PMnv Mme jc BY DNS D.lrteeen IrNv.tI.BY D.b Cemmem.: ACCOUNTING ONLY: AIDo FAC! PE CODES FEE INFO AMOUNT RERRTTED CHEC"MARM RECEIVED BY DATE FENRT/SETVICE FEOUFIT NUMBER INVOKE