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APPLICATION FOR WELLIPUMP PERMIT USAN JOAQUIN COUNTY PUBLIC HEALTH SERVICIETO ENVIRONMENTAL HEALTH BIVISION P,O, BOX 388,304 EAST WEBER AVENUE, STOCKTON, CA 9520E-388 12091468-3420 NOR•REFUNDABLf PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1r."'P1416 In TTIPRcsts) APPLICATION N HERE EL MADE TO THE SAN POAOVIN COUMTW'FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY ELTITLE,CHATEq�-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTTY PPUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSroR APNI IZD [�/ _ Err ^ + PARCEL SIZEJAPNS OWNER'S NAME - / 11 AbDRE88 � &-- _-��.,ONE CONTRACTDR�GiL�4.L PHONE f6 �� OUR CONTRACTOR.._ TYPE OF WELL/ MP: ❑ NEW WELL ❑ REPLACEMENT WELL © MONITORING WELL S ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CA OSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL {TYPE OF Pt7MPl �,/ O 11 DESTRUCTIbN: IJ OUT-OF-SERVICE WELL 11OEOPHVSICAL WELLd 13( SOIL BORING Or7L 8 INTENDED USE TYPE OF WELL OOHBTRUCTION SPECIFICATIONS A INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINDISTEEUPVC DIA.OF WELL CASING O O FUSUC/MUNICIPAL ❑DISVEN DEPTH OF GROUT SEAL ePECtFICATION 11 ❑�/IRRIOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME -y E IJ M'.WTOR ING GROUT SEAL PUMPED: ❑Yep Ne CONCRETE PEDESTAL BY DRILLER;❑yee ❑Ne 3 APPROX,DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONFMO1 UN0 METHOD! MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE-MOY CERTIFY THAT 114AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAW.,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB 18SUE13,1814ALL 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 WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' I11�,AIr IC NT MUST CALL 2�NOU •IN ADVANCE FOR ALL REOURED INSPECTIONS AT 120401488,242=, COMPLETE DRAWING AT LOWER AREA PROIVIDE .IOD. nsd% 'w- j TRIA [A Date_i PLOT PLAN Prow to Score)Salve '!e 1. NAME.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 E. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, STRUCTURES,INCLUDING COVERED AREAS SUCH A.PATIOS,DRIVEWAYS,AND WALLS. ON THE PROPERTY OR ADJOINING PROPERTY. t� DEPARTMENT USE ONLY AppSoetlen Amopled By Id 7J �� Gate Aru Grein Inapoetlon By Dale Ptenp Inspection By Dote beavtietlen lnapeatlw,BY bete Commetwe! ACCOUNTING ONLY; IUoo FACS PE CODES FEE INFO AMOUNT REMITTED C ASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE 46=1 Pub.Health Serv.-Enviro.173(3196) f, ///