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APPLICATION FOR WELLIPUMP PERMIT V USAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 38% 304 EAST WEBER AVENUE, STOCKTON, CA 95201 X88 {209) 469.3420 NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED {Complete In TTlpHowlsl APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WTTH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.11 15.31�A1�ND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRERS/OR APR# S. 2 F_ LOr_��rt_7�_ S Y " CIT/ {Ln]126{i(! PARCEL Sl2EIAPNR dZ— 9�j OWNER'8 NAME rJDL"Y\-_1 1 ADOREBS .-7 PHONE a +� CONTRACTOR rGG �\ `\ �h�l. y ,ADDRESS 2 ' �1 LIC/ PHbNEN.,,J�`p.9c7�7�� SUBCONTRACTOR�JIDP..-C.T��I./�'\!'� 1r.1C�JLp�%Ca,.�.(f1\ + `1'L c- "ADDRESS�.7� W I'al W(/�✓L LICN 2 '? PHONE a q4 "u r(Z TYPE OF WELLMIUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONrronwo WELL or ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O STYPE of PUMPi IJL^[J, Dr W�OVT•OF-SEflVICE WEL! ❑ QEOPFIYSIC AL WELL/ �-OIL BOfVNQ � B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION all DIA,OF CONDUCTOR CASINO D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGfSTEELIPVC DIA.OF WELL CASINO �f O ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY 5111,6 GROUT BRAND NAME k1 E ❑ MONITORING GROUT SEAL PIMPED:RYw (IN. CONCRETE PEDESTAL BY DRILLER:❑Yw ❑No S APPROX.bWtH LOCKING CHESTER BOXISt OVE PIPE S PROPOSED CONSTRUCTION/DRILLINO METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER 1 HVIEBY CERTIFY THAT T HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATION e 4 THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS IS 188 ,t III NOT EMPLOY REASONS SUBJECT TO WORKMAN'S COMPENSATION 1J1W8 OR CALIFORNIA.' CONTRACTOR'S HIRING DR BUD-CONTRACTING SIGNATURE CERTIFIES THE LLOWINQ: 'f ERTiFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1$HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAIJ A.' THE��CANT MUST CA 2 URE 1 OV E FOR ALL REQUIRED INSPaECT1ON8 AT 12081 4011-3421. COMPLETE DRAWINO AT LOWER AREA PRSOOjVVIIDED. Slpned X T1tle__ Q�i Dot*__[ �/r / PLOT PLAN IDraw to Septa)Beata 'to 1. NAMES OF STREETS OR ROADS NEAREST T O BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUttINE OF THE PROPERTY,GIVING DIME S NO AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WTTHIN RAOIU8 OF ONE HUNDRED FIFTY FT, STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. 44 J DEPARTMENT USE ONLY ApPSeatlon Accepted By (f// � l �- OMr J1A Arw Orau1 Irwpxelen 8y ,(�.FZn_q.s Date Pu P Impaction SY Date Dwlnmllen Ir peeflon By Date Ce Merka: ACCOUNTING ONLY: AID/ FAC/ PE CODES FEE INFO AMOUNT REMITTED CHECKIifCASII RECEIVED NY DATE PERMITIAE71VICt REQUEST MUMMER INVOICE 6g 3g 6 � zl g l3Y -d,S Pub.Health Serv.-ERviro.173(3196)