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APPLICATION FOR WELL/PUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 TEAR FROM DATE ISSUED 1Gmplets In TRIpIICBtel APPLICATION 19 HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPUANCE%RTI/SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND TH�E{[STT'A/NDDAF08 OF SAN,IOAQUI"COUNTY PUBLIC HEALTH SSERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESEIOR API/ //� J"itf t MIO It A �l r Y�'L CITY/�R - �" PARCEL SIZEIAPNI q'1'[9 C- Z3-/ OWNER'S NAME ry r I ADORE881Q L-,iE11� 1U �� IL I I1 / PHONE IC/L'//J /J+��L2. CONTRACTOR 6Se--l" an MP S A..'"" Pf VlI/Fy ]11tli , � f7 `FNONE�i `� Z'3S�v SUB CONTRACTOR ADDRESS Il ,�ILIC/ RHONE TYPE OF WELL/PUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL/ ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CPOSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL I ✓ ❑N—❑P—.4 H.O. DEPT"RUMP SET FT. FIRST WATER LEVEL O (TYPE OF RUMP) �( ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELLI SOIL ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIRCATIONS A ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O 11DOMESTICIMVATE ❑GRAVEL PACK/SIZE TYRE OF CASING/STEELPVC DIA.OF WELL CASING O ❑PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑XWOATION/AG tR OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑MONITORING GROUT SEAL PUMPED:❑Yr ❑N. CONCRETE PEDESTAL BY DAILLER:❑Yr ❑NP 5 APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONSTRI/CTIONMAILUNO METHOD:MUD ROTARY AIR ROTARY AUGER CABLE OTHER 64'l/P(, ��.. 1 HMSY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE S1 ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND MULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S MIRING OR SUB-CONTRACTMO SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY T THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFO A. CANT ST CALL 2 LURK 1 DVANCE FOR ALL REOUIREO IIN&MCTIIONN-S�AT 12051 41SJ12S.COMPLETE DRAWING AT LOWER ATEA PROVIDED. /,,(� ..—I x TRU. V PLOT PLAN ID,—I.So.41 So.W 'Io L.NAMES OF STREETSPROPOSED OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4.LOCATION OF"OUSE SEWAGE DISPOSAL SYSTEM OR PPOSED 2.OUTLINE OF THE PROPERTY,OWING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 7.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WIT SN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINRIO PROPERTY. I L.� .................. r .... /. / D.FAATMENT USE ONLY APPBe.Ibn A...PI.d er {//(1 f/ D.I. Grout IMP---BCO. on.InFu.n In.P.cBen Br D.I. C.mmsH.' ACCOUNTING ONLY: MDI FAC/ PE CODES FEE INFO AMOUNT REMITTED CHECKI CASH RECEIVED■Y DATE PERMIT/SERVICE REOUEST NUMBER INVOICE I rao 133 1 9 Pub