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APPLICATION FOR WELLJPUMP.PERMIT__ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CAV5202 (209) 468-3420 NOIFREFUNDARLE PERMIT EXPIRES i YEAR FRGI DATE ISSUED (CBmplatt In TIIplie�sE} APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOil INSTALL THE WORK DESCRIBFO.THIS APPLICATION 19 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11153.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY�PUSUC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB AOORESSIOR APHI / �'_,z4e,1-a r s r-_-cr, C:�. El— PARCEL SIZEJAPN/ OWNER'S NAME !_1 C ADDRESS - O Tc ✓PHONE N v tw t>m I I r ` CONTRACTOR _ JQ III` f{SS �} �� CR i $US CONTRACTOR O Y uA�OREBB �i I} E . I C E j DYE OF WELLlPUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONRORGNG WELL 4 ❑ OTHER 1 ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CR098-CONNECT REPAIR ❑ VAPOR EXTRACTION WE11./ ❑Neje❑Repair H.P. DEPTH PUMP SFT FT. �. FIRST WATER LEVEL O (TYPE OF PUMPI ❑ OUT-OF-SERVICE WELL ❑ OEOPHYSICAL WELL/ �'' ❑ SOIL BONNO S ❑DESTRUCTION- INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS iii A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO I p ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISRE TYPE OF CASINGISTEEI.IPVC � DIA.OF WELL CASINO p 11PUBI.IClMUNK:TPAL ❑DMVEN DEPTH OF GROUT SEAL � SPECIFICATION q IRRIOATM/AO ❑OTHER GROUT SEAL INSTALLED BY �? OT10UT BRAND NAME E TRTOPUNG � GROUT SEAL PUMPED: ❑Yr ❑No CONCRETE PEDEBTAL BY DRILLER:❑Yee ❑Ne S A OX.DEPTH LOCKING CHESTER BOXMTOVE PIPE g 3 PROPOSED CON/TRUCTIOKIDRILLIMO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE'tEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DOME IN ACCORDANCE WITH 9ANiJOAGUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AN IIEGULATPONS OF THE SAN JOA COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING!•I CERTIFY THAT IN THE PERFORMANCE OF THE WOPK FOR WHICH THIS PE IT IS ISSl1E0,1 Slf NOT5CA Y PERSONS SUBJECT TO WORKMAN-/COMPENSATION LAWS OF CALIFORNIA_' CONTRACTOR-13 HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES ' THE FO O 1 CERA THAT PERFORMANCE OF THE WUTRK FOR WHICH THIS PERMTT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WGROMIAN'S COMPENSATION LAWS OF CALJFO APPUC MUST24 HOURS IN ADVANCE FOR ALL REOUIREO INSPECTIONS T 12061 44f4144211. COMPLETE DRAWING AT LOWER AREA PROVIDED, �F /f owned TINa Date��r/ J� � itJ, OT PIAN IDrew to Sc.le]Saala 'to P. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDSNG THE PROPERTY. j!4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2- OUTLINE OF THE PROPERTY.OTVBNO DIMENSIONS AND NORTH DIRECTION. FXPANVON OF SEWAGE 00SPOBAL SYSTEMS, 2. DIMENSIONED OUTLINES AND LOCATION Of ALL EXISTING AND PROPOSED S, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. - BTRUCTURES,0 CLUDINO COVERED AREAS SUCH AS PATIOS,DMVEWAYS,AND WALKS. ,j ON THE PROPERTY OR ADJOINING PROPERTY. .. _.r 1U E ........... :. °. . ..... . DEPARTMENT USE ONLY 2 Dalai 3 -' A.« Applleatlen Aeoepted By C� w 140`0 O,mA"Peetlen B7 AN^IC:=% Dote 1 P�P IMP an By �� Date D"Irtmdon Impectlon BY G 31113 tj - - KA0 7-r JM,0- Date :1 Cernms+ta: II ACCOUNEINO ONLY: -AID/ FAC/ F PE CODES" FEE INFO AMOUNT REMITTED CHECKf/CAAH RECEIVED BY DATE 11 PMMTISEHVICE REOUEIT NUMBER INVOICE 3 -v .no 03 3 zZ ; Pub yeatth Serv.-EnviTG.173(1197)