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1PPLICATION FOR WELLIPUMP PERMI- SAN-mOAOUIN COUNTY PUBLIC HEALTH SED,..,tCES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON, CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICempkts In TrlpDeets) APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WrTff SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. 11 JOS ADDRESSIOR APN/! !! ` 1— J 1 CITY q� ) PARCEL BIZFJAFY!! �j/.� OWNER'S NAME �-/1-4 ADDRESS /[/r/V3I VV. �!�y'f Q,�^ PHONE! '_2�S-pfiZ CON1IRACTOP1__"kQ DDRESSZ6(/3 . A+"G71......,.,._.._UC/ PHONE R SUS CONTRACTOR ADDRESS tic! PHONE! TYK OF WELLIPUMP. �(❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL I 13 OTHER J�J,INSTALLATION © WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J R YPE OF PNMPI 13 N.IJRep Nr H.P. DEPTH PUMP BET FT. FIRST WATER LEVEL O ❑ OUT-OF-SERVICE WELL © GEOPHYSICAL WELL It ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WE�LL�e11 CONSTRUCTION SPECIFICATION! ' A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p ❑ DUMEStICJPRIVATE ❑GRAVEL PACK/VIZE TYPE OF CASINGlSTEELA VC GIA,OF WELL CASING O ❑ PVBLIClMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION g ❑ 3MUGATIONIAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yea ❑Ne CONCRETE PEDESTAL BY DRLLLER:❑Yr ❑No 5 APPROX.DEPTH LOCKING CHESTER BOXMTOVE PIPE g PROPOSED CONSTAUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR GUS-CONTRACTING SKONATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORTS FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120914SI.f422. COMPLETE DRAWING AT LOWER AREA PROVIDED. 619+ % Thto DHa PLOT PLAN 1Drayv to Scald Scala '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. E%PANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALSS, ON THE PROPERTY OR ADJOINING PROPERTY. DEPARTMENT USE ONLY J Aovncrilvn A�aptad By Data Area Grain kopectyn It Data Rmp Impaction By Data Onat—tlen Ir.apacticn 9y Data carom 0! ACCOUNTING ONLY; AIDI FACT K CODES FEE INFO AMOUNT REMITTED CHECKIICASII RECEIVED BY DATE PWMITISERVICE REQUEST NUMBIR INVOICE Sf7 1 8 0 6 g� -97 o S' Pub.Health Serv.-Envlro.173(1197)