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PPLICATION FOR WELLIPUMP PERW SAN wOAQUIN COUNTY PUBLIC HEALTH SERA ICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Completb In Trip ientn) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITII SAN JOAQUIN COUNTY DEVEL AENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# .: / Cfry / PARCEL SIZE/APN# WN /./✓�, ��yJ� ].,�,I OER'$ NAME _r r. /zt,,. , AODRESG SAA7 'J N ' ,l , 9At l. PNON�! • �+ ��0(/f/ LIC# PHONE / ay CONTRACTOR ✓, / ADDREB ,76 SUB COMMCTOR / N ADDRE68 / " Z I F LI joy /) PHONE l /5 TYPE OF WELVPUMP: ❑ NEW WELL ❑ REPLACEMENT WELLMONRORING WELL # ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # J ❑ New ❑ Remaly H.P. DEPTH PUMP SET PT. FIRST WATER LEVEL D (TYPE OF PPMPI ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL tl ❑ SOIL BORING S ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL 11 OPEN BOTTOM DIA. OF WELL EXCAVATION /? DIA. OF CONDUCTOR CASING 0 ❑ DOMESTICIPRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC� DIA. OF WELL CASINO `7—�— p ❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEALS IFIATION ❑ IRRIGATION/AO ❑ OTHER GROUT SEAL INSTALLED BY Y TT' GRAND NAME ❑ MONITORING GROUT SEAL PIMPED: ❑ Yr 0 m J CONCRETE PEDESTAL BY DRILLER: ❑ ee ❑ Ne S APPROX. DEPTH LOCKING CHESTER BOX/STOVE PPE 8 PROPOSED CONSTRUCTIONIORILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOM WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGEM'S SIGNATURE CERTIFIES THE FOLLOWING: At CERTIFY THAT IN THE PERFORMANCE OF THE WORD FOR WHICH THIS PERMIT 18 ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: ' 1 CERTIFY THAT IN THE PER 0 MANCE OF T WOR( FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPFN6ATON LAWS OF CALIFORNM.'/�/ 1Enj. PICANT M q IN ADV CE FOR ALL REQUIRED INSFECRON4 AT 12"14gJ11f. COMPLETE DRAWING AT LOWER AREA PROVIDED- Big X V _ is a" Title Date_ T PUN PDT" to Scale) Scale ' to 1 . NAMES OF STREETS OR ROADS NEAREST TO OR BOUN G THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY, GIVING DIMEN610N6 AND ORT" DIRECTION. EXPANSION OF $MADE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXI INO AND PROPOSED S. LOCATION OF WELLS WRHHN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES, INCLUDING COVERED AREAS SUCH PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, v - S DEPARTMENT USE ONLY Application Accepted BY Date / Area Grata Inapeetlon By Date "o Inspection By Date Omtnmaen Inspection By Date ACCOUNTING ONLY: AID# FAC# PE COOEB FEE INFO AMOUNT REMITTED CHECK2/CABH RECEIVED BY DA 'EJPERMITISERVICE REQUEST NUMBER INVOICE / 7a S Pub. Health Serv. - Enviro. 173 (1/97)