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APPLICATION FOR WELLJPUMP PERM[ SA&AQUIN COUNTY PUBLIC HEALTH SI*ES T A ENVIRONMENTAL HEALTH DIVISION / ?. 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED O R 1 G I N A t (Complete In Triplk11lel APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.Title APPLICATION IS MAGE IN COMPLIANCE WTTN BAN JOAQUIN COUNTY DEVELOPMENT Ta/te CHAPTER/9I-1115/.3 AND THE STANDARDS OF BAN JOAOUIN COUNTYPUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH owtal 1!. 1�'w p,-1 JOB ADDRESS/OR APNI137y /.i AICOIIJ ( P n1T.F(- CITY 1%0141 PARCEL SIZE/APNI t M ,LQw)tA Se<+1 �D.�CRIBaw� De "oc Csccns) /9100Ptwul St. /Z /ems OWNER NAME L 0. L�R,J �A 1 F t�(et ReeWADDRESI E;O Au,'tbe , CR 9V(OP-/QA� RIONER S/O'(Pj.7'YJ�O CONTRACTOR ADDRESS LIC( PHONE I ewt d. eve covrRAclGR�jr'« �,-5'i�u I.,,c_ ADOR1EeeMar ICA3 9YS63 LICt (aSGVO7 PHO HE -3iS-SPK TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑Nmv❑Roo.1, H.P. DEPTH PUMP SET_IFT. FIRST WATER LEVEL O R YPE OF MMPI ❑ OUT OF SERVICE WELL ❑ GEOPHYSICAL WELL It ® BOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS II A 11 INDUSTRIAL ❑UPENBOTTOM DIA.OF WELL EXCAVATION eI'Ln QJiPS DIA.OF CONDUCTOR CASINO 0 ❑ DOMEBTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEELJPVC A//F7 DIA.OF WELL CASINO A)/IQ / 0 ❑ PUBLICRAUNICIPAL ❑DOWN DEPTH OF GROUT SEAL 'J'07'0/ lJogJ -A SPECIFICATION Ctowl.J1- b.-.IfOAI%Fl R �JJ ❑ IRPoOATgN/AO ®OTHER OROITI SEAL INSTALLED BV (IOAl7FYETF �TO(" OROVTBRAND NAME A///7 E ❑ MONITORING ` GROUT SEAL PUMPED: ®Yr ❑N. CONCRETE PEDESTAL BY DRILLER:❑YM (3 No A/%)I S APPROX.DEPTH Ls D LOCKING CHESTER BOXISTOW RPE___dZZ& _ // 5 PROPOSED CONSTRUCl1ON/DRIWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER OIY i S/y?U 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN JOAOOIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE POLLOWINO:'I CEITTIPY THAT IN THE PLRfORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIMES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 8HAM EMPLOY PERSONS SUBJECT TO WORXMAN'S COMPENSATION LAWS Of CALIFORNIA: THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED IINS/FECTIONS AT 12011114114128. COMPLETE DRAWING AT LOWER AREA PROVIDED. 9l.W X Till. �11ref-/ POW p/^ Dna PLOT MN IM.le SPYeI B A. 1. 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 1. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSMNB AND NORTH DIMCTMN. EXPANSION OF#MADE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,ORVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. MHP t?t?� c. cL1cd� . ......PAYM DEPARTMENT USE ONLY ^p� �Y��L4 -9(�f Ggx MPIIcnIUR AecePlM By D•,• O �'I 'FI0 999 �1R OroU ImP.POen By DO. PB r 1nP.n1PP By Dole Doo"". ..Im0ePlbn ByD SAN JOAQUIN COUNTY ENV �18NEI IEA HEALTH DIMS( ENVIRONMENTAL HEALTH DIVISION OPTmeWN.: ACCOUNTING ONLY: AID# FAC# PE CODES FEEINFO AMOUNTREMITTED CHECK#MASH RECEIVED BY DATE PLRMIT/BERVICE REQUEST NUMBERINWICE 0 o�g Pub.Health Sew.-Enviro.173(1/97)