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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PORLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON. CA 95201388 (209) 488.3420 NON•REFUNOABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 20 -36160a IComPNtf in TrIoNc8181 APPLICATION N Y DE EL MADE TO THE SAN POAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND INSTALL THE WOW DESCRIBED.THIS APPLICATION 16 MAGE IN COMPLIANCE WITH SAN 115 JOAQUIN COUNTY EVELOPNENf TTrjTLE,CHAPTER 9-1 .3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE.,ENVIRONMENTAL HEALTH DIVISION. (J�, v-d JOB ADDRESS/OR APNI I 1 WIUiQt ^V,. t CIT-11 IJP `P� �,/A PAtiRCEL SIZEIAPN/ OWNER'S NAME LL 4` �X ADDRESS_ [�t't 14 l.ry G") '1 7241 y� 5'P'- PHONE CONTRACTOR ew, 41x : ADDRESS (_II"1 f cj UC/ PHONE I�_ OUR CONTRACTOR ADDRESS -� �5`>4% UCIs� I Z PHONE I TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLI J New 11RepairH.P. DEPTH PUMP SET FT. FIRST WATER LEVEL (TYPE OF PIMP) pI� O - '( OVT OF-SERVICE WELL —0 GEOPHYSICAL WELL I SOIL BORING ❑DESTRUCTION: dt / ✓✓�'rr 11��` \�I i `R INTENDED USE TYPE OF WELL P- CONSTRUCTION SPECIFICATIONS � - -�--- 11INDUSTRIAL 11A OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC OIA.OF WELL CASINO El D PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION 11 R IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E MONITORING GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER:❑Yea ❑N* s APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONBTRVCTION/DrtlLL►NO METHOD: MUD ROTARY AIR RD RY UGER CABLE OTHER 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WILL BE DONE IN ACC I DANCE- BAN JOAQUIN COUNTY ORDI NCE.,&TAT WS,AND RULES AND REOVLATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERrORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWIN '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT T WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' APPLICANT MUST CALL 24 URS IN ADVANCE FOR ALL REQUIRED IN TIONS AT 1209)400,2428. C DRA NO T LO R AREA PROVIDED. 810ned X Title ( CJ �{� 1J 7 - l r Data 1 ICS PLOT PLAN(Mew to Solve)Scale 'to 1. NAMES OF STREETS OR ROADS 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. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAE SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, SSSS. _' .. .. •'. �.��_____ IV - y _r Y - Jys• y y y„ ,SSSS 'sl/ x,4 - 10 .. SSSS O ....1� t1 I yz• ' o i "►nom O s n e - __ .,- SSSS.„ _x 4'_.. y.• oati2 acvELL ' K�_"'a-.6.:.+C.......�.-m..,.�m�•�•^..a.., '_:.14aM4 Y w,wsrow tsar` : - DEPARTMENT USE ONLY � �J Application Accepted By LAS Data--S�_ qr" Z� Grout Inspectlon By Date Pump 1-pectlen By Date Doew.tlon fnvpsotjon By Date Commd•tr A .00" ACCOUNTING ONLY: AIDI FAC/ PE CODES FEE INFO AMOUNT REMITTED CHECKI/CASH RECEIVED BY DATE PERMIT/BFJIVICE REQUEST N11M861 INVOICE 72 ) 0-31 Pub.Health Serv.-Enviro.173(3/96) t 00�