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APPLICATION FOR WELLJPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete IR Triplicate) APPLICATION 19 HERE BY MAGE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3^AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMSION. JOB ADDRESSOR APlN#616 S e P7 ^41�� 91 • CRY�I4--( .g-aA PARCEL SIZEIAPNI ^ p OWRJER'B HAMEM�Y I QUIPM G�_ AErV 4 L ADDRESS 910",-'F PHONE RO(� / CONTRACTOR r/54,1f E T/'V l�.I N I`'t cn/% L.� Q yy ADORE88 � 5 •�1"''G UC/b838E25 PHONEI SUB CONTRACTOR ADDRESS UCI PHONE TYPE OF WELL/PUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL Ir ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ ❑New 0 Amolr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-0F•SERVK:E WELL ❑ GEOPHYSICAL WELL# SOIL SORIN a ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS.7 i A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION d ' DIA.OF CONDUCTOR CASINO D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO D ❑ PUSUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL-V'� L-'Ep.tf SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY D�I�",�R GROUT BRAND NAME E ❑ MONITORING r GROUT SEAL PUMPED: ❑Y.. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yes ❑Ne S APPROX.DEPTH / `+3e LOCKING CHESTER BOX/STOVE PIPE Q .r�,L� s PROPOSED CONSTRUCTIONIU MI METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER DiAF-C-T P,61+ 1 HMBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCE9,STATE LAWS,AND RULES AND REGULATIONS Of THE SAN JOAQUN COUNTY HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES T14E FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB IS 81IALL NOT EMPLO RSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR#U"ONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 1 CE IFY THAT N Tl RFORM �QRK FOR WHICH THIS PERMIT 18 ISSUED,I#HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFONNIA.' A CANT MUST LL SHO V FOR ALL REQUIRED INSPECTIONS 2ATIZOe1 Rafe�J�'t2f. COMPLETE DRAWING AT LOWER AREA PRO D. SRtn.d X TIN. I� `3 C`• ;;V3 Lf Date PLOT PIAN(Dr.w to se-1.1 go.lo to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. S. LOCATION OF HOUSE SEWAGE DISPOSAL SYBTEM OR PROPOSED 2. OUTINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE D48POM SYSTEMS. 3. DIMENSIONED OVTLNF.S AND LOCATION OF ALL EXIBTNG AND PROPOSED S. LOCATION OF WELLS WITHIN RADII/B OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ` u n. I � J I 1 DEPARTMENT USE ONLY Applle.tlen Aeeepted By k2 D.t. Ar.. Grout MNpeetbn By�n t!N Dote 0 Ptenp Impeetlen By ON. OMtraetbn Impaction By Dot. Comment.• ACCOUNTING ONLY: AIOI FACS PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DAXE PERIhITI#EAVICE REQUEST NUMDER INVOICE d O D `1 O Pub Health Serv.-Enviro.173(1/97)