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'rPPLICATION FOR WELUPUMP PERM" SAE AOUIN COUNTY PUBUC HEALTH SEi, ES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Tripfiolltel APPLICATION 16 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WIT11 SAN JOAQUIN COUNTY DEVELOPM'EENTT TITI9 0.111R..3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. _ JOB ADDRESS/OR APNJ '� J_I.� �` v'7C. crry PARCEL SIZE/APN# I ADDRESS 9 OWNERS NAME PHONE I CONTRACTOR % ADDRESS J 7F4ONE /� SUS CONTRACTOR j/t/�G 1 C/!�/�/� ADDRES-Y iq -s�ec'r�lG /U�C�PHONE I� 1.L1- TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL J ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL J J ❑New❑P..w, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O HYPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL If 6011 00RIN0 S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA-OF WELL EXCAVATIOH DIA.OF CONDUCTOR CASINO D ❑ DOMESTIC/PRIVATE ❑ORA�V L PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASING O 11PUBLIC/MUNICIPAL L►YDRIVEN DEPTH OF GROUT SEAL r-- S_ SPECIFICATION ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME F ❑ MONITORING ^ GROUT SEAL PUMPED: ❑Yee ❑Ne CONCRETE PEDESTAL SY DRILLER:❑Yw CIN. J APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE / s PROPOSED CONSTRUCTION/DR(LUNO METHOD: MUD ROTARY AIR/10TARY AUGER CABLE OTHER I HEgESY 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 AND PFGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR UCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:11 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH T1/IS PERMIT IS ISSUED,I SSIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRINO OR IIUSCONTRACTING SIGNATURE CERTIFIES T//E FOLLOWING: CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA` CANT MUST A SIN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091400.3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. SIQr.nd X Tltle D.I. PLOT FLAN(Drew to See1e1 SeNe to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. t. 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 OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAE SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, I! .. ... .... .. ..... .. ..:... ...... DEPARTMENT USE ONLY G AP011eeO..Aco Id ByL�L ij 1J+1Mw L'104-- Dne -1 Mee Groin 1—11-BY (AIAA-11y D■te�PvnP lnroectlen SY Dete D,..vuellen In■nectlan By Det■ Cnmmerm: ACCOUNTING ONLY: AID/ FACS PE CODES FEE INFO AMOUNT REMITTED CHECK/!CASH RECEIVED BY DATE PERMITISMACE REQUEST NUMBER INVOICE I Da �3 I Pub.Health Serv.-EnvirO.173(1197)