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� APPLICATION FOR WELLIPUMP PERMIT } AN JOAQUIN COUNTY PUBLIC HEALTH SER . , ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388,304 EAST WEBER AVENUE:, STOCKTON, CA 95201 88 12091468-3429 110WREFUNDABLE PERMIT EXPIRES 7-YEAR FROM DATE ISSUED ICampwu In 7ripUeata) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT 70 CONSTRUCT AND/OR tNSTALL THE WOW(DESCRIBED.TIRE APPLICATION IS MADE IN COMPLIANCE NRTII SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHA/PTTER 9-11 116'.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLICHEALTHSERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APNI 157/ �A19 ifi r6ci #40hof rLq4499— CR/�Y��r�/�-� PARCEL B12ElApNI Q +J OWNER'S NAME J _ ADDRESS TE�[.1� ' NE f `� / Z d CONTRACTOR r AbbAE88 / LICI lP = PHONE I Q� SUB CONTRACTOR I IG T( �lQj ADDRESS t 1 r LIC#G7�PHONE 17I�9,5{9 �] oz 4 TYPE OF WELLIPUMP. NEW WELL ❑ REPLACEMENT WELL �MONRORING WELL RIJ OTHER _ I ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL J ©New❑Repair H,P. DEPTH PUMP SET Fr. R YPE OF F1/MP1 FIRST WATER LEVEL O © OUr-0RSERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOi4 ROWNa 0 ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONf J 11 A C1 INDUSTRIAL 1�1 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING e ❑ DOMESPURUCI UNICVATE L.IIGRAVEL PACKISIZE � TYPE OF CASINOISTEEL�_�j 1 DIA.OF WELL CASIN�vjg O ❑ PUSLICIMUNICIPAL ❑DRIVEN 5f}'jJ 1� DEPTH OF GROUT SEAL_ SFECIFICA710N -- 7 �'/ R I ❑ FRRIGATIONIAO ❑OTHER r GROUT SEAL INSTALLED SY��iF'I��P GROUT BRAND NAME I / [-.yof E 1J' MONITORING GROUT SEAL PUMPED: I]Ye. O Ne CONCRETE PEDESTAL BY DRILLER:❑Y� l�Ne � S ' APPROX.DEPTHORSnr� LOCKING CHESTER 0�11OVE PIPE S PROPOSED CON#TRUCTIONIbWLLING METHOD: MUD ROTARY AIR ROTARY AUGER-jt'" CABLE OTHER ik I I, I HE9ERY CERTIFY THAT 1 IfAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL RE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORgINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGEM'8 SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWINO: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOAKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THEA ANT MUTT CAS 24 URS 1N ADVANCE FOR ALL REQUIRED INSPECTIONS ATr12001 460.3422. COMPLETE DRAWING AT LOWER AREA PROM//pEb, f�''7 Signed X Title p Dole Z� PLOT PLAN(Drwv to Saetal Beale 'to , I. NAME#OF STREETS OR ROADS NEARERT TO OR BOUNOM THF PROPERTY. 4. :LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUNE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. S. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOR,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY, ' .:....S....-.......... .. . .......... .. .. - -- .. .. .. - ; DEPARTMENT USE ONLY - �_..-��. - Apprkeflen Aeeepted BY '' Dole 1 I�li� Ar" G—A Irnpeetlen Sy Dole Pu-p Impeotlan By Dote Deatrtellen Impeetlpn BY Dote Cemmergr ACCOUNTING ONLY: AID# TACO PE CODE$ FEE INTO AMOUNT FIEMITTED CH !CASH RECRVED"Y DATE ;PETIMITI#FSHVICE REOLwmT NUMBER INVOICE � r Pub.Health Serv.-Enviro.173(3136)