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APPLICATION FOR WELIJPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL.HEALTH DIVISION 384 EAST WEBER AVENUE, STOCKTON, CA 952 (209) 468-420 D NON-REHAVARLE PERMIT UP1RES 1 YEAR FROM DATE ISSUED C 00 (Ump4t6 In TTIIIIIII I APPLICATION IB HERE BY MADE TO THE SAN JOAOVIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOFK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAGUIN COUNTY DEVELOPMENT 71TU.CHAPTER 8.1 115.3 AN THE STANOAROS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEB,ENVIRONMENTAL HEALTH OM SON, JOB ADDRESSIOR APMf CITY V b PARCEL SIWAPNf S T OWNER'S NAME ADOI�BS � PHONE (w`�/+ CONTRACTOR ` ADDRESS LIC/� PHONE�f L!!tiC SU4 CONTRACTOR ADORES! TYPE Of WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELLI' f tj 0 11 OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR Cl VAPOR EXTRACTION WELL/ J ❑N.w❑Re•dr H.P. DEPTH RUMP SET FT_ FIRST WATER LEVEL O 11 YPE OF PUMP) ❑ OUTdFSERACE WELL ❑ OEOPHYSICAL WELL f ❑ BOR BORING B ❑DESTRUCTION: INTENDED USF TYPE OF WELL CONSTRUCTION SPECIRCA71ONS �! A ❑ INDUSTRIAL ��❑77LT OPEN BOTTOM DIA_OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO D ❑ DOMESTICIPRIVATE 1p{GRAVEL PACxmFZ TYPE OF CARN6111ITEELIPNC OIA.OF WELL CASINO__ _T D ❑ PUBLIC/MVNICIPAL (u.�DRIVEN DEPTH OF GROUT6EJLL SPECIRCATON ��•.J77�� R ❑ IRWGATIONIAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAM �y E ❑ MONI IHG GROUT SEAL PUMPED: I�Y— ❑Na �+ ONCRI{TE PEDESTAL BY DRILLER:❑Y- �Me S APPROX.DEPTH LOCXfNG CHESTER BOXISTOVE RIPE Ifr S PROPOSED CONSTRUCTIONIDAIWNG METHOD: MUD ROTARY AIR ROTARY___)�_AUGER CABLE OTHER I HEREBY CERTIFY THAT 1 IIAVE PREPARED TWO APPLICATION AND 714AT THE WORK WILL.BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS-AND RULES AHO REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH _ THIS PERMIT IB ISSUED.1 914AL.L NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP£NOATION LAWS OF CALIFORNIA.' COPRHACTOITO HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'f CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERII IIT IS IBSUED,I SHALL EMPLOY PERSONS SUSJECT TO WOR10IAMS COMPENSATION LAWS OF CAUFOP;IIIA.- APPLICANT MUST CALL 2�HOURS IM ADVANCE FOR ALL REGUIRM INSPECTIONS AT I"tl ASS-'L177. COMPLETE WING AT IOVYE7l AF>EA PROVIDED. ` pp ` d StQ.,.d X TItl. �qo "1..r ` D.e. PLOT PLAN 10—is Sa.4I Sad. M T_ NAMES OF STREETS OR ROADS WAREBT TO OR BOUNOING THE PROPERTY. 4- LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on PROPOSED 2. OUTLINE OF THE PROPERTY.GIVING DOAENBIONS AND NORTH DIFFCTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS, I. DIMENSIONED OUTLINES AND LOCATION OF ALL ERISTINO AND PROPOSED S. LOCATION OF WELLS WITHIN RAMS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DfEVEWAY9,ANO WAUCS. ON THE PROPERTY OR ADJOWN4 PROPERTY. 1 DEPARTMENT USE OFILT AppOcNlen Aeaapred By DoleAr. Orwr I++.peerlen By Ow Rmp In.vaaelen By ' O.0 be.be�Ilan InrP.etlen ey D.t■ C... n..l.: — DZ !� r ACCOUNTING ONLY: AIOf FACS PE CODES FEE INFO AMOUNT RgATTm CHECXEICASH RECEIVED■Y PATE or I P@01tlTlSEhVICE hEOUEST IUM09L INVOICE Pub.Health Serv.-Enviro.173(1/97)