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APPLICATION FOR WELLI'PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MainpI6t6 iN Triplkatel APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 19 MADE IN COMPLIANCE WITII SAN JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 --11 1155..3�AND1 THE STANDARDS OF SAN JOAQUIN COUN�TY']PURLIC HEALTH SERVICES,ENVfMNMEHTAL HEALTH DIVISION. JOB AOOMSMR AP/NI 2 11-7 E•'`)�1`��cyt7-`VN 7 J T Cm �T-�''^^-`--' PARCEL S12EIAPNN OWNER'S NAME W l le C—AAA)1/LL- r^ M IZ ' ADDRESS -5,4 I-L C _PHG-E/ 943- 2W+ CONTRACTOR A(4VAA)c.EiD GeQ&)V/1a/ ADDRESS 400,5 6),k); I sa J ZZ-7 PHONE/ +t07—/00 SU18 CONTRACTOR ADDRESS LIC/ RHONE/ TYPE OF WELL/PUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONAORNG WELL/ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J ❑Now❑Rohr H.P. DEPTH PUMP SET --Fr. FIRST WATER LEVEL O (TYPE OF PUMPI �( ❑ OUT-OF-SERVICE WELL C1HSIC OEOPYAL WELL/ CU SOR BORING B DESTRUCTION: Grol,� c sar-Cpw� bo7rom - INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O ❑ OOMESTIC)P/VVATE ❑GRAVEL PACK/BRE TYPE OF CASINO/STEEUPVC OIA.OF WELL CASINO O ❑ PUBUC/MUNICtPAL ❑DRIVEN OEPTH OF GROUT BEAL SPECIFICATION B ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT BEAL PUMPED: ❑Yee [IN. CONCRETE PEDESTAL BY DRILLER:❑Yw CIN. S APPROX.DEPTH 30/ LOCKING CHESTER SOK/STOVE PIPE S PROPOSED CONSMUCTIONMIILLNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE-WRY CERTIFY THAT I IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR BUD-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORIOMAN'6 COMPENSATION LAWS OF CALIFORNIA.- THEAPPUC�NT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS AT(2061 448-5423. COMPETE DRAWING AT LOWER AREA PROVIDED. SIOr.ed X� TI". r�1� ,,I m� / l Dole ROT PLAN(Drove to 60.1o1 Selo 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. j. DIMENSIONED OtfTU1NF8 AND LOCATION OF ALL EX19TING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATHOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOIN"PROPERTY. top-. ILE DEPARTMENT USE ONLY App400tlon Aoeepted BY /�tii�( � N.I,vt./%>_ Dole ' / % Ares Grew ImpeaUen BY �..�-�'V1 li GI'. Dole I Z 1 IGC P—D lr o tion BY Dole Oe.utetbtt 1—0—BY Otl• Co...memr: ACCOUNTING ONLY: AID/ FAC/ PE CODES FEE INFO AMOUNT REMITTED CHECX/ICASH RECEIVED■Y DATE PERMITISERVICE REOUEST NUMBER INVOICE o� I gab ealth Serv.-EnvirG. 173 (1'971