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r 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 OATE WHO (Complete In TrlpOnte) APPLICATION 18 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TTR�IEE..C A 1 115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB AOORESS/OR APNi**A'f'ro • 5c X1.00 5 M+s CITY I o,4 l PARCEL S12E/APNI r OWNER'S NAME 4:11:1 of LOC S ADDRESS 3�f ��` tk a PHONE f a 6 7Q 6 CONTRACTOR Q YC VI C<d G�O r k N I No N MI<N.�� ' ADDRESS �00,�J �A - W `50o W LIC/ 610;l->7 PHONE IN(7-100 O RUB CONTRACTOR 541 I S �X P 10 r1 f f Vk 5-M V)C e-1 A0011Ett 86 3 W hrwlTrlJf4 P4 eucs TYPE OF WELLUPUMP. ❑ NEW WELL ❑ REPLACEMENT WELL CJS,MONITORI NI WELL I ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ./ ❑Now❑R...M N.P. OEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-OFeERVICE WELL ❑ GEOPHYSICAL WELL S ❑ SOP.BORING S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q A A ❑ INDUBTRIAL p❑�OPEN BOTTOM DIA.OF WELL EXCAVATION V DIA.OF CONDUCTOR CASINO D ❑ DOMESTIC/PRIVATE 110 ORAVEL PACKMZE * 3 TYPE OF CASMW/STEEUPVC V G OIA.OF WELL CASINO /• D ❑ P1SLICIM UNICIPAL ❑OAMN DEPTH OF GROUT BEAL ) 4O/ SPECIFICATIONS jrcl.4 R ❑ IRRIGATION/AO ❑OTHER OROUi SEAL INSTALLED BY f wR#N'1 L OROVT BRAND NAME �A' a E 1x MONITORING r ORDUT SEAL PUMPEO: QI Y. ❑N. CONCRETE PEDESTAL BY DRILLER:❑Y. 0++• S APPROX.DEPTH 61 LOCKING CHESTER SOXMTOVE PIPE S PROPOSED CONSTRUCTION/DRILITNO METHOD: MUD ROTARY AIR ROTARY AUGER— A. CABLE OTHER 1 HEEBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND REOULATON8 OF THE SAN JOAOUM COUNTY. HOME OWNER OR LICENSED AOEHT'S SIGNATURE CEWIFIES THE FOLLOWING:'1 CERTIFY THAT W THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WOM MAN'S COMPENSATIORI LAWS OF CAUFORMA.' CONTRACTOMS HIRING OR$UBCONTRACTMO SIGNATURE CERTIREO THE FOLLOWING: 'I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH 1H18 PERMIT 19 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORIWIAN'S COMPDI$ATWN LAWS OF CALWORMA.' THE APPLICANT MUST CALL _�2A HOURS II ADVANCE FOR ALL REQIRRM INSPECTION$AT 12M 4$$J.22. COMPETE DRAWING AT LOWER AREA PROVIDED. e1a»+x �N'(iC�%ti'1NIi'`► TIII. SP. 51a ff (vv to f 0.1. I t X14 PLOT PLAN Mow t.So-W SW. 't. 1. NAMES OF STREETS OR ROADS NEAF49T TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR POPOSED 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTUNF.t AND LOCATION OF ALL EXWTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES.INCLUDIHO COVERED AREAS SUCH AS PATIOS.DRIVEWAYS.AND WMXS. ON THE PROPERTY OR ADJOINM PROPERTY. DEPARTMENT V8!ONLY A..S..11at Aes.P1.d BY O'eut MwP..tf. By Date Puno 1r406.tl.tr BY ON. O..tntetlen Irw..etbn 8Y D.0 COrnnM1M.• . ACCOUNTING ONLY: AIDS FACS R CODE$ FEE INFO AMOUNT RETIITTED C11ECK1 ASN RECEIVED$Y DATE PO MITISERVICE REQUEST NUMBER INVOKE Y,. H Pub Health Serv.-Enviro.173(1/97)