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APPLICATION FOR WELLJPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplow M TRipRnt$1 APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOW DESCRIBED.TIDE APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1 115.3 AND THE STANDARDS OF SANS} QUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION.JOB AOOREBS/OR APNI V ! a" CITY 1 -- PARCEL SIMAFNE •�(� J OWNN:R'S NAME t Y PHONE 8,j/ L - I`O I / CONTRACTOR �gvRQ 14C+c( �'�o F7+tNj IrOVIAil.-A � wcoREBo 4005 M..Wjlfo:o W,(y uce 40;*7 PHONE, 417`1066 RUB CONTRACTOR 50115 etc p loliN hO4 5'"V It-5 ADDIEss l,53 4 F v tA't rt4, t fQ_,j 5Qc uce PHDNE�.16 TYPE OF wELt/P1JMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONSroRIG WELL i ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J ❑N_❑R. .6 H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF RIM% Cl OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL M ❑ SOD.sORMG S ❑DESTR MTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION$ IF A Q ❑ INDUSTRIAL p❑OPEN BOTTOM INA.OF WELL EXCAVATION 0 J DIA.OF CONOUCTOR CASINO D ❑ OOMESTICMRIVATE 09 GRAVEL PACXretZE 3 TYPE OF CASM019TEELMVC � f_v (_ VIA.OF WELL CASING � D ❑ PUSUWMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 40' SPECIFICATION 5-ch- L4 D R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY I r"W IL I t GROUT BRAND NAME t1 A E 031 MOMTOIENG J GROUT SEAL PUMPED. IN Y. [IN. CONCRETE PEDESTAL SY DPNLLER:❑Y. ®N. s APPROX.of"" 6i LOMINQ CHESTER BOXISTOVE PIPE s PROPOSED CONSTRUCTFOWDIMLUNO METHOD: MUD ROTARY AIR ROTARY AUGER,_CABLE OTHER 1 HPEBY CERTIFY THAT t HAVE PREPARED THIS APPLICATION AND THAT THE WORL WILL BE DONE M ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WL11CH THIS PERMIT IS ISSUED.1 SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S NIDND OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT M THE PERFOAMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SMALL EMPLOY PERSONS SUBJECT TO WORT MAN'S COMPMSATION LAWS OF CALIFORNIA.' THE APPUy�CIANIT MSUUST-CALL 24 HOURS IN ADVANCE FOR ALL REOUNI®INSPECTION$AT 120SN 408-3422. COMPLETE ORAWALOWER AT LOER ATEA PROVIDED. skrwd X�1AA/ U'rl/r�/k.v(.L�y Tlv. 1 - s�Q ��?a�0 i S 1 D.t. II^fq'q PLOT RAN IOr~to S.w1 S.N. I. 1. NAMES OF STREETS OR MADS 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. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. DIMENSIONED OUTUNf.S ANO LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAE SUCH AS PATIOS,ORiVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOIMG POPERTY. - - DEPARTMENT USE ONLY ANPS..tbn A.~.d BY 's(,S A C/�lL �'VM�C'4^Z OM. 3h. Qt m k-p—til.n BY f AM,,A,-� On.�Pum►Irn...tl.n BY ON. bn.tnatl.n I.wp.etion BY Do. Canmetw.: - ACCOUNTING ONLY: AIDS rAcs PE CODES FEE INFO AMOUNT REWTTIED CHECKOICASH RECEIVED DY DATE ►BWMTSEVICE REQUEST NUMSEI INVOICE •-o+ Pith 4amth Sary.-Ebviro. 173(1/97)