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APPLICATION FOR WELLJPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION ORIGINAL 304 EAST WEBER AVENUE, STOCKTON, CA 95202o(209) 468-3420 �RON-REFUNDA®LE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED f �,qq5 t,-(0� (Complete In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WrTII SAN JOAQUIN COUNTY DEVELOPMENT TITLE; CHAPTER 0.1115 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION.. JOB ADDRESS/OR APNE - �U • CITYPARCEL SIZE/APN/�/n/ /(�JEf l OWNER'S NAME �/I• _ ADDRESS �--5 /�i�v'�� _/%Tj PHONE R�,�/�(j CONTRACTOR _ cS ADDRESSZ/�L J Gy� C_ LICE '� PHOI�'*'/Z• TYPE OF WELL/PUMP: IN NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL / ❑ OTHER /� El INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ® VAPOR EXTRACTION WELL A1.3 C e R2t4k,' N//� ❑ New 1] Rep.lt H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT -0F -SERVICE WELL ❑ OEOPIYSICAL WELLE ❑ SOIL BORING a Ll INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS nn ,�I 11lam' INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION _� (O� /O! j,/ " DIA. OF CONDUCTOR CASINO W114 ❑ DOMESTIC/F'riIVATE ❑ GRAVEL PACK/SIZE_ TYr'E OF CASINO/ST EEVF'VC �%�C /�C%ICFIiC 7 O DIA. OF WELL CASINO " �-)o? E Zt� �pi y�� O ❑ PUBLICIMUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL ((11 6/ / SPECIFICATION p❑ IRAIGATION/AG 11 OTHER GROUT SEAL INSTALLED BY �1tt.C7 &bnlia GROUT BRAND NAME= Oso 7--�J P..ri ►�M/ E (.q MONITORING/e) /"d k,, GROUT SEAL PUMPED: ICI Ye. ❑ No CONCRETE PEDESTAL SY DRILLER: ❑ Ys. ®Ne S �' APPROX. DEPTH ?o LOCKING CHESTER BOX/STOVE PIPE VeS S PROPOSED CONSTRUCTIOWDAILUNO METHOD: MUD ROTARY AIR ROTARY AUGER XT_ CABLE OTHER 1 HE-MBY 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 REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WIIICH 1 THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: - 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR NMtCH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OFA CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS AT 12001408-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. TItI. N�e D.t. t- TT PLOT PLAN 1Orew to Ik.I.I S-1. - 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 AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, Appee.tto� O—A Incl 0— ,-1. C —A ACCOUNTING ONLY: AIDE FACT PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED By DATE PERMITISERVICE REQUEST IRaN013\-' INVOICE t, 0 YdR oat � o Pub. Health Serv. - Enviro. 173 (1/97)