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y. APPLICATION FOR WELLlPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ! ENVIRONMENTAL HEALTH DIVISION 1 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NON•REFUNDARE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CBIRpMb In TrlpUealal APPLICATION 19114EPE RY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TILE.CHA�PTTERi 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DMSION. JOB AbbRESeIOR APN# - d' �iJ lv CJ CITY " ..J'[�[,k+0}� PARCEL S12ElAFN/_ OWNER'S NAME'.Ey��.r - 6Cat `'l ADDRESS OQ �Cr�O -__-_---. ----- _-_--/-__--rPwNEE' CONTRACTOR !I" ; n r8 Iv Q1n 1�� ADDRE99 { eI',S f,� �'�� LIC* 5D�y"'PHONE0' 7G J�V SUB CONTRACTOR ADDRESS LICIT RHONE# TYPE OF WEI.LlPIMF: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR © CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J 11 New❑P"* H.P. DEPTH PUMP BET Fr. FIRST WATER LEVE! O (TYPE OF PUMPI 11 OUT-0F-SERVICE WALL ❑ GEOPHYSICAL WELL R Soil-BORING ❑DESTRUCTION: INTENDED USE i TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL€ ❑OPEN BOTTOM DIA.OF WELt EXCAVATION d '�.►if1 __ _ VIA.OF CONDUCTOR CASING 0 ❑ DOMEATI 7 IF VATE 13 GRAVEL PACKIME TYPE OF CASINOISTEELIPVC INA.OF WELL CASINO D ❑ PUBLICAdUNICIPAL ❑DRIVEN DEPTH OF GROUT SEACroimt vnievh& SPECIFICATION A ❑ IRRIGATION/AG ❑OTHER (TROUT SEAL INSTALLED By 1 1�+�1AR1 I� GROUT BRAND NAME! t tMledTRC f � R - ❑ HR MORORINO 3? R 3 - yy GOUT SEAL PIMPED:P1Y. ❑Ne CONCRETE PEDESTAL:'BY DRILLER: Yee ❑Ne S APPROX,DEPTH LOCKING CHESTER BOXISTOVE RPE S PROPOSED CONGTRUCT1ONIOMLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HMBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF,THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I WALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPQISATTON LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTMCTBKT SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORIQAAN'S COMPENSATION LAWS OF CALIFORM APPUC�W�1\1f M Lai{IN ADVANCE FHM ALL REOLaRIM INSPECTIONS AT I20a1 4"J422. COMPLETE DMNANO AT LOWER AREA P`ROO]VIb b. Stpned X - Title Date { ! PLOT FLAN mkm to Seale)Solve 'to 1. NAME@ OF STREETS OR ROADS NEAREST TO OR BOUNDING TIRE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED - 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. S. DiMEHIPONEDI'OUTLINF.9 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RAbIVS OF ONE HUNDRED FIFTY FT. STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK$. ON THE PROPERTY OR ADJOINIIIO PROPERTY. 1 ...., ... .:.. ........... .. .. .. .. - - - ., a....: :. ....:. :. .. .... ..:. .. .. ., .. .. .. - .... DEPARTMENT USE ONLY 'I Apocallen Aesepled By .:( `�1•,�� vim` Det* '7--Ir Aree_ d)7 J L ' G+oot k*peet%n BT Det@ Pimp Inepeotlen BY - Dole Daelnetlen Impeetlen By Date Cemmeme: J i I: �r ACCOUNTING aNLY: AID# FAC! PE CODE@ FEE INFO AMOUNT REMITTED CHEC"ICASH RECEIVED aY DATE PEMOTISEAVICE REQUEST NUMSEPi INVOICE 9 37- 1 Pub Health Serv,'-Enviro.173(1197)