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APPLICATION FOR WELLJPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES APR _ 2 L ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON,CA 95202 (209) 468-3420 `= NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in TrlpRelltal APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER B-1 11 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN! J/ q(o "J. ,�pvlSi Stat CITY_ /� �9— � JMiJTC.r``r¢ PARCEL 812E/AFN! .2(ep OWNER'S NAME <h l Z SIX fo .y A—k-r L _ LNC ADORE88 y� y L;p -` PHONE It 27- ��NLrsI '%k/ J / CONTRACTOR G�F..� h,4ZL.t. i C_%LS:-.,y lA✓"L. ADDRESS ` UC! PHONEY^f' Silt—.SSSS • %6D St PUB CONT MCTOR�,r,�.C.[S�y+_t 5.4�.,y0/.,�.' ADOR£Be� r 6,.....ro,.� LICK&�l:, E?7 PHONE TYPE OF wELL/PUMP: NEW WELL ❑ REPLACEMENT WELL I MONrTORINO WELL!_Ajw ❑ OTHER �( INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL! J ❑New❑Repel, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ITYPE OF PUMPI ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS y t / ' A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION .Z-s�` �'�' 1 DIA.OF CONDUCTOR CASINO O 11DOMESTIC/PRIVATE KGRAVEL PACK/SIZE /Z TYPE OF CASINO/STEEIJPVC 3 /re—F DIA.OF WELL CASINO ❑ PUBUCAAUNICtPAL ❑DRIVEN DEPTH OF GROUT SEAL_ GV SPECIFICATION f q ❑ IRROATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME ( L'..t_r-C. E KMONITORING GROUT SEAL PUMPED: PfYr ❑Ne CONCRETE PEDESTAL BY DRILLER:OYw [IN. S APPROX.DEPTH Z� �-.� LOCKING CHESTER BOX/STOVE PIPE }� r g PROPOSED CONSTRUCTIONMMLLMO METHOD: MVD ROTARY AIR ROTARY AUGER CABLE OTHER fJ e E-J- PLj I HM13Y CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAGUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING*'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 814ALL 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 PERFORMANqf OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPMSATION LAWS OF CALIFORNIA.' THE CANT MUST CALL=DVANCI FOR ALL REQUIRED INSPECTIONS AT 12t>•1/00-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. elp.bd X Tltl.�r0� �COLO�i�i� JDate PLOT PLAN(Oraw to Soalol Saab 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING 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. 2. DIMENSIONED OUTUNF.S AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN MONS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. 3 l DEPARTMENT USE ONLY Applleatlen Accepted Byh LL K Date f' Arw � .� Oroul lmpeetlen by LLQ A A/�r r-- Oats Ptsnp Imooetlen By Date ' j beatnreUen Impeetbn BY Date - Comment.! ACCOUNTING ONLY: AIG! FAC! PE CODES FEE INFO AMOUNT REMITTED CHECK!/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE Cl .va3-2-3-L-4b D S OU cz S It Pub Heafth Serv.-Enviro.173(1/97)