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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 368, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 (209) 469-3410 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOn INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOA ADDRESS/OR AF'NI ,� CIT/Cr / PARCEL SIZE/APN/ � 0 � OWNErt'S NAME C.- 4�JS�..c�i�,[)� r�i=�1Lr�/i fes/ �/� ADDRESS_ --AS i PHONE f CONTRACTOR /�L fI/�, C��'7 ADDRESS T I U SUBCONTRACTOR �•i/%'l�(r�'Gyf„/� �tk PL1!✓��J7T/G Ii�1I � PHONE ADDRESS LICA PHONE I TYPE OF WELUPUMP; ❑ NEW WELL ❑ RFPLACFMENT WEI-L ❑ MONITORING WFLL A ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL A (TYPE OF P11MPI ElN—❑R.oelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT-OF-SERVICE WELL ❑ OEOPHYSICAL WELL* SOIL ROnINO 8 ❑DESTRUCTION: �/`C`7�/�' � ��[.�(� � \ INTENDED USE TYPE OF WELL CONSTRUC110N SPECIFICATIONS - A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_ DIA.OF CONDUCTOR CASING U ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STFFUPVC DIA.OF WEI L CASINO D ❑ PURLIC/MUN!CIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IPRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Vee [IN. CONCRETE PEDESTAL BY DRILLER:❑Y- [IN. S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CON8TRUCTION/DRILLING METHOD: MUD ROTARY t� AIR ROTARY AUGER CABLE OTHER — I HERFRV CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BF DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNFR OR LICENSED A(IFNT'S SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUR CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFOnMANCE OF THE WORK 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 12001408-3422. COMPLETE DRAWING AT LOWER AnFA PROVIDED. - Tltle C�-y1.� "�'�- Date /�2 PLOT PLAN 1Drew to Sof.)Soel. 'to 1. NAMES OF STREETS OR ROA NEAREST TO On BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BV8TEMS. 3. DIMENSIONED OUTL INFB AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STSUCTUnES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY On ADJOINING PROPERTY. .. II DEPARTMENT USE ONLY Gj ApplloeH.n Ae..pterl ey_� l � Arae Grout Irnp.etlon BY D.t. Pump irnpo.tl.n By Dote D—tntell.n Irnp-11—By Det. Comment.: ACCOUNTING ONLY; AID# FAC♦ PE COVES FEE INFO AMOUNT REMITTED CIIECKAICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE (011 ) 59 Pub.Health Serv.-EnvirO.173(3/96)