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` PPLICATION FOR WELL/PUMP PERMI` SAk oAOUIN COUNTY PUBLIC HEALTH SEN, . ES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NOB-REFURDABLE PERMIT EXPIRES 1 YEAR FROM RATE ISSUED [Complete In TTiplleat9[ APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT 70 CONSTRUCT AND/OR INSTALL THE WOW( DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1119.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OP APN2 CITY PARCEL SIZE/AMR OWNER'S NAME - ADDRESS - PHONE [ - - CONTRACTOR - ADDRESS Me PHONE 9 SUB COMPACTOR ADDRESS -r" Z i LIC9 PHONE 0 TYPE OF WELL/PIIMP: ❑ NEW WELL ❑ REPLACEMENT WELL 1:11MONTORING WELL S ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 9 J ❑ New ❑ Repair H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL O (TYPE OF MMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL S ❑ SOIL BORING 8 ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING D ❑ DOMESTICAHIVATE 11 GRAVEL PACK/SIZE TYPE OF CASINGISTEEVPVC DIA. OF WELL CASING D ❑ FUBUC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION - R ❑ IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: El Yea LINO CONCRETE PEOESTAL BY DRILLER: ❑ Ves ONO 5 APPROX. OMNI LOCKING CHESTER BOXnFMVE PPE S PROPOSED CONSTRUCTIONMAILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HE?EBV CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES ANO 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 KRUM 18ISSUED" I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'B HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: ' 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120914885122. COMPLETE DRAWING AT LOWER AREA PROVIDED- Signet! X - - , -. TWO Date , ROT RAN 10rauv to 50001 Seals I . NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED G. DIME' STRUT w Qf - )RED FIFTY FT. za u a Z zn K ®' O — 3r . . w Q lai Z a r Z Of � c : . . .. . . Q F N o O O O w w Z o O J a •� M x 3 x z a Z ° w x 0 {A w w 0 Y N H N 4 0�- 0 O Z O O _ Z m P s _ CD CD m 3 tl31NRH w w a u z li�- o- O a3onnN ONIMHO • 0 0 DEPARTMENT USE ONLY Application AaaepteA By Dale Area Grave Irrcpeceon By Date PVmp InacoetIon BY Dale Ueatraemlen Inspection By Date Cemmenla: ACCOUNTING ONLY: AIDS FACT PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMITREIIVICE REQUEST NUMBER INVOICE Pub. Health SEN. - Enviro. 173 (1 /97)