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PPLICATION FOR WELL/PUMP PERMr SAN 'a43AOUIN COUNTY PUBLIC HEALTH SERYTCES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468=3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TrlPliCMt#) APPLICATION 15 HERE BY MADE TO THE SAN JOAQUIN COUNTY FORA PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 IstW AND THE S ANDAROB F SAN OA'-Q�UcIIN CO HTY' PUB ALL" SERVICES, ENVIR AL HEALTH DIVISION, JOB ADOREs3roR APNI f - � 45TSf �.-9DCLrc�G/�/ c•lCt96uc, ,rye p 1� CITYPARCEL5IZE/APNfOWNER'S NAME / e/�.'yL�I �L YL pDORE38PHONEIF 0 CONTRACTOR L74('* ADOREScPHONE F U'U'40d � JBUB CONTRACTOR Zi �S ADDRESS F v B PHONE D / 0 3. TYPE OF WEUJPIMP: ❑ NEIN WELL ❑ REPLACEMENT WELL 0. MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J ❑ NeIv ❑ Repalr N.P. DEPTH PUMP SET FIT. FIRST WATER LEVEL O RYPE OF PUMP) ❑ OUT-OF-6ERVICE WELL ❑ GEOPHYSICAL WELL # ❑ BOIL BORING B ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 4 ❑ INDUSTRIAL 11 OPEN BOTTOM DIA. OF WELL EXCAVATIONDIA. OF CONDUCTOR CASING 0 ❑ DOMESTIC01PRIVATE ❑ GRAVEL PACKISIZE TYPE OF CASINGISTEELiPVC - � � DIA. OF WELL CASINO 2 � 0 ❑ PUSUCRAUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION _ R ❑ IRRIGATIONIAG ❑ OTHER GROUT SEAL INSTALLED BY GROW BRAND NAME ❑ MONITORING GROUT SEAL P merM 171val CONCRETE PEDESTAL BY DRILLER: w ❑ Ne S APPROX. DEPTH LOCKING CHESTER BOXISTOVE PPE S PROPOSED CONSTRUCTIONIdtlLUNO NUMB: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE MTN BAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF THE CAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWINO: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED, 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SURCONTNACTINO SIGNATURE CERTIFIES THE FOLLOWING: ' 1CERTIFY THAT IN TI PERFORTT�rANCE OF THE WOW FOR WHICH THIS PERMIT 16166UED, I SHALL EMPLOY PERSONS SUBJECT TO WORXMAN'S COMPENSATION LAWS OF CAUFORNM.jTiLE APPUCAI}TJ,1U 1 15 DVANCE FOR ALL REQUIRED INSPECTIONS AT 120111 /M312S. COMPLETE DRAWING AT LOWER AREA PROVIDED. slarod XY/u/ni /�/ '(��Li T/A TIRe Date PAT PAN IDraw to Scale) Seale to I . NAMES OF STREETS OR ROAOS NEARESTTOO OUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY. GIVING DIME N81 NB AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYBTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED C. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. DEPARTMENT USE ONLY Applleetlen Aeetarel By Data / I Area Grew Iropeetlen Or Date Pump Inapactlen By Data D"I"Fllen Iroractlen By Dale Comm"Is: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO MOUNT REMITTED CHECK#ICASH RECEIVED BY D TE PERMITISERVICE REQUEST tiUMBER INVOICE .Q Pub. Health SEN. - Enviro. 173 (1 /97)