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APPLICATION FOR WELLJPUMP PERK• SA OAOUIN COUNTY PUBLIC HEALTH SE ICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompIEtE In TIIIiksto) APPLICATION le HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMR INSTALL THE WORK DESCRIBED.THIS APPLICATION le MADE IN COMPLIANCE WRIT BAN JOAQUIN COUNTY DEVELOPMENT �/TITLE.CHAPTER B-1/11.15.7 AND THE/STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DM�SION. ^�{ JOB AODRESB/OR APNE��1(p,EL_q �lqoR&jTQ6J RUA0 _CITY Ln01 PARCEL SIZEJAPNPCl✓(�y+ � .�$ (jS2J� OYMER'SNAME�IR JK,IL A-KAPry - 1_. T ADDRESS�� CAPr PA` A,�vt, _STONE0 Zo-1 � aL0'77cJ I CONTRACTOR OM1 -jr%00 1Qo A/v��ilfon/Y1P/±m— Tl( ADDRESS 'If)05(71V' Willy% •1'�Un ZL10E 22 RbNEo 104 /671004 BUB CONTRACTOR `P is l I)LOIN+ Al011'1 A.+' ADDnEesF' L7' GX Ori/a uCS 1,35&76;o RbNE I I l 52 bZb TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL KmoO MORINO WELL P M W •� ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROS&CONNECT REPAIR ❑ VAPOR EXTRACTION WELL P J ❑Naw❑Hepelr H.P. DEPTH PUMP SET-_--p. FIRST WATER LEVEL 0 HYPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL ROBINS E ❑DESTRUCTION: INTENOEO USE TYPE OF WELL CONSTRUCTION SPECIFICAHONS A ❑ INDUSTRIAL ❑OPEN BOTTOMCC,,,, DIA.OF WELL EXCAVATION r L DIA.OF CONDUCTOR CASINO_ 0 E] DOMESTICNNVATE �PMVEL PACK/SIZE 3�7lNA TYPE OF CASING/STEE C✓ OIA.OF WELL CASING - 1 D ❑ PUSUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEA T e J SPECIFICATION I A �y❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLEDiii B��Y''' 1RGM/ OROVTBMND NAME E Jy MONUOM" Cy-�E GROUT BEAL PIIMPEO: Igor ❑Ne CONCRETE PEDESTAL BY DRLLIN:gY. ❑Ne S APPROX.DEPTH � 1 GL / Ir7�V� LOCKING CHESTER SOXIBTOVE RPE —ii 1 QX S RIOPOSED CONSTRKICT,MGgLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT I HAW PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISBUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTMCMNG SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS KAMM IB ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' TIE APPLICANT MUST CALL 111 URB IN ADVANCE FOR ALL REOMIIED INBRCTIONBCATCIZOBI A22-0/951 B'B� COMPLETE ORAWINO AT LOWER AMA PROVIDED. SIGro X TIIIe S 1 A I 1 li "a Dna PLOT PUN(Drew le Sedel Bede 'le 1. NAMES OF STREETS OR GOADS NEAREST TO OR BOUNDING THE PROPERTY. /. LOCATION OF HOUSE SEWAGE AL SYSTEMS.SYSTEM 00 P/IOi'OBEO 1. OUTLINE OF THE RWPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION F BEWAOE THINEGGRRADIUS SYSTEMS. 3, DIMENSIONED OUTLINES ANO LOCATION OF ALL EXISTING AND PROPOSED B. N THE PN OF WELLS WITHIN RADIUS PE ONE HUNDRED FIFTY FT. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,ANO WALKS. ON THE{'ROPERTY OR ADJOINING PIbFERTY. AW DEPARTMENT USE ONLY Deb T Ara APPIIC7A..I.M By Grern lapalla ev Dne Pump lmP-"tl By One mb Oavmllen IrNParbn Br Cemmnue: ACCOUNTING ONLY: AIDJ FACE PE CODER FEE INFO AMOUNTIEMITTED CHECKF/CAS RECEIVED BY DATE PERMIT/SERVICE REGUEET NUMBER INVOICE Pub.Health Sew.-Envlro.173(1197)