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ORIGINALAPPLICATION FOR WELUPUMP PERMI� P M / ( N A L S�AOUIN COUNTY PUBLIC HEALTH SE ESENVIRONMENTAL ALTH DIVISION BUR �y 304 EAST WEBER AVENUE,TOCKTON, CA 95202 Nov (209)468-3420 o�IN�pUN Y ,J �� NOALREFUNDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN��HEA'JHFSESHp�tStpt� (COMPIEtE In TFIPR,EtS) Pp6l1�EN1A N APPLICATION 15 14E BY MADE THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMA INSTALL THE WOR(DESCRIBED.THIS APPLICATIOk MADE IN COMPLIANCE WRII SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY MBUC HEALTH SERVICES,ENVIRONMENTAL HEALTH IN COMP. JOB AODRESSMR APN, S/ 5'j PRG 1 Gi A✓C,_Vvt PARCELSIZE/APNS OWNER'S NAME �/��L�/'SJT,//.VI P�LT� CS%l�rE qS J:JtJ ADDRESS PHONE,zU r/ 9Sy�-lJ� CONTRACTOR CL/TRK Cl-/654e, //YL, ADDRESS 2-'%0y E GrH�F.+rA-fiP llC,�-�7/'.�Q PHONE, 0047 SUBCONTRACTOR �' c'r-rt7N y6, -7 ADDRESS UC, - 7( PHONE/ TYPE OF WELL/PUMP' ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL, ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR 13 OTHER ❑N. M.P. 11VAPOR EXTRACTION WELL, J 0 YPE Of PUMP) RWSit DEPTH PUMP SET---yr. FIRST WATER LEVEL O 13 ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL, . 601L BORING rEs'r A .e/AI�< OE6TRVCTION: T B INTENDED USE TYPE OF WELL CONaPUCT10N.PECIFICATION6 ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATIONA 11 ' OOMEBTIC/pRIVATE ❑GRAVEL PACK/SIZE ryP OF CASING/STEEL/PVC DIA.OF CONDUCTOR CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN OLA.OF WELL CASING D tAAAA----�..�__ DEPTH OF GROUT SEAL SPECIFICATION ONIATIONO ❑OTHER GROUT SEAL INSTALLED BY T BRAND NAME E GROUT SEAL PUMPO: ❑Yr ON. CO CRETEE PEDESTAL BY DRILLER:Ely. ❑Ne S MONITORING APPROX.DEPTH LOCKING CHESTER BO%/STOVE PPE PROPOSED CONBTRUCTION/dtlLUNG METHOD: MUD ROTARY_ qlR ROTARY S AUGER CABLE OTHER I HEREBY CERTIFY TIIAT I IIAVE PREPARED THIS A1`PUCATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN 115c1IN COUNTV 011111 1 1N: :l,WFATE LAWS,AND RULE.AND REGULATIONS OF THE.AN JOAQUIN COUNTY, HOME OWNER OR LICENSED AMENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PEWORMANCE OF TILE WOW FOR YMICH THIS PERMIT 10 ISSUED,I SMALL NOT EMPLOY PERSONS 8 JECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OB BUDCONTRACTINGSIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT IN THE PEWORMA E OF THE WOIIK FOR WHICH THIS PEnMN 18IB.UED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUfORN1A.- THE APPIEANT MUST CALL 24 HOURS I ADVANCE Oq ALL REGUIRED�roINSPECTNS AT 12,014"d 23. COMPLETE OMWING AT LOWER AREA PROMO .I,—I X TIIIe �%GLc/V1- DNe / Z do POT M Eben to S,NaI BeNe •le 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 2. OUTLINE OF THE PROPERTY,GIVING DIMENBIONB AND NORTH DInECTION. 4. LOCATION OF HOUSE.,WAGE AL SYSTEMS.SYSTEM OR PnOIb6E0 G. DIMENSIONED OMUNF.B AND LOCATION OF ALL EXISTING AND MOPO.ED EXPANSION F SEWAGE DISPOSAL 8 OF ON. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. 8. LOCATION OF WELLS ADJOINING RADIUS OF ONE HUNDRED FIFTY R. ON THE PROPERTY OR ADJOINING PIIOPERTV. /Y r SSSS —� Y'^I P .! `c =.. :SSSS... . ,... ENr use ONLY Avelln.en Aeeepted BY �-+\ C (,f`�4 I�� Opb ) V � Mu OreN Imp«Ileo By O.te Rnnp Impmtlon er Orte 0/ Omm�tle,Imo«tbn By DNe Cemmeme ACCOUNTING,ONLY: AID, FAC, PE CODED EE IMO AMOUNT REMITTED CHEcK CASH RECEIVED BY DATE PEAMIT/SEAVICE REQUEST—PLUMBER INVOICE 3s�7 IS ii 0o :z Li ,7 353 3 Pub.Health Serv.-Enviro.173(1197) ORIGINAL