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APPLICATION FOR WELL/PUMP PERMIT / L 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 SATE ISSUED ICampiata In 7rkfkmloi APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDA7R INSTALL THE WORN DESCRIBED.TI08 APPLICATION IO MADE IN COMPLIANCE WrTll SAN JOAQUIN COUNTY DFVELOJ++PM``EHT TITLE.CHAPTER 8-17 15.3 Amo OF BAN JOAQUINB C HEALTH SERVICES,ENVIRONMENTAL HEALTH bMB10N. JOB ADDRESSIOR APHr ,, PARCEL SQFJAPNr OWNER'S NAME d�CONTMC70RADL1Cl , �bNEeUB CONTRACTOR A ` -7)�[//'{(// Ucr f ,JI rl rJ-�PHOHEr �1 T'YPE OF WELtJMMP: ❑ NEW WELL 90PILACTMEWIT WELL ❑ MOFNTOfVNO WELL r ❑ OTHER ❑ INBTALLATIORI Cl WELL SYSTEM REPAIR ❑ CR098-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r J (TYPE OF PUMP) ❑Hew❑Revek H.P. DEPTH PUMP SET FT. FF9T WATER LEVEL O ❑ OUT-0F-SERVICE/WELL ❑ OEOPHymAt.WELL r ❑ WR SORINO ]yL S 491 DESTRUCTION- !` ? 1 1 J /I INTENDED USf TYPE OF WELL CON RUCTION SPECIFICATIONS I Q ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION ORA.OF CONDUCTOR CASINO 0 ❑ OOMESTICIPFRRVATE ❑GRAVEL PACXIII1ZE TYPE OF CASINGfSTEELAINM ORA.Of WELL CASINO D ❑ PUBUCIMUNICIPAL ❑13mvEH DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E Cl MOMTop-HO GROUT REAL.PUMPED: [1Y— ❑RIe CONCRETE PEDESTAL BY DRILLER:❑Y— ❑RTe S APPROX.DEPTH LOCKDO CHESTER BOXMOVE RPE S PROPOSED CONST14UCTIOMMMLUNO METHOD: MUD ROTAFTY AIR AOTARY AUGER CABLE OTHER I HERBY CERTIFY THAT I HAVE PREPARI{D THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE CAN JO A OUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING,"I CERTIFY THAT W THE PEFWDRMANCE OF THE WORK FOR WHICH THIS PERMIT 1818BUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING qR BUB..CpMRACTING SIGNATURE CERTIFIES --- -� THE FOLLOWRNO; -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS PROVED,1 SHALL EMPLOY PERSONS SUBJECT TO WORIWAN,COMPDRSATION LAWS OF CALIFORNIA.' PRICANT MU(T C T4 HOURS IN ADVAHCE FOR ALL REOU{AED ITIRIP4CT10N1 A IYO.1 7ffJ�12], COMRI.7ET7:OFLAWI►O AT LOWER AREA PRO D, 5 ��/ mal Olal d X �y�✓ _ TILL• L D.1■ PLOT RAN ID,e le Sell Beaie 'to 1. NAMES OF 9TREETB OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4- LOCATION OF HOUSE SEWAGE LNSPOBAL SYSTEM OR PROPOSED 2. OUTLINE OF TILE P"OPERTy,QIVOO DIMCHMONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUFTLINF9 AND LOCAT30H OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADm OF ONE M1HOfWD FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS OUCH AB PATLOS.DFW.FMAYS,AND WALK& ON THE PROPERTY OR ADJOINING PROPERTY. Olt ............_........._.... DEPARTMENT USE ONLY ADplkellen Aeeepl ed By Dele A+w Orwl M>•Pslbn Sy �� D.Re Punp lerep"I Ry DNA. O.�.trvlkn Ir,.pactlen D.1• C e..rn.sM.• / j ACCOUNnNa ORILY� Aror FACT PE COOED FEE INFO AMOUNT REMITTED CHECIUlCASH REL` JI ETVED SY DATE P9v48T1SERVICE REOUE3T NUMBER INVOICE Pub.Health Sarv.-Enviro.173(1/97)