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APPLICATION FOR WELUPUMp PERMIT D J r6 �[j T SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Q ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 &• �� (209) 468-3420 PCOMAPLIAINY� .] NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complat$ In Trlplkat/IAPPLICATION IS HERE BY MAGE TO THE SAH JOAQUIN COUNTY FOR A PERMIT 70 CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED THIS APPLICATION 18 ADE I SAN JOAOUIN COUNTY DEVELOPMENT TITLE CHAPTER 9 1115 3 ANO THE IFTANOAR138 OF SAN JOAOUIN COUNTY PUSUC HEALTH SERVICES ENVIRONMENTAL HEALTH DMSION JOB AOORESS/OR APNF L CITY l raL,-- P RCEL St.ZTJAPNF OWNER 8 NAME 1 -2121 - L- a'Y+AL1 ,,,.Z 2; Gam' ADDRESS AJC y PHONE �j p CONTRACTOR (� ADDRESS 23 6 y Syl LACI /(� Zy PHONE F I(�' 2LE�_�( (aFi SUS CONTRACTOR ADORE68 L1CO PHONE F TYPE OF WELQVUMf- ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONrrovo4G WELL• ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLF J ❑ TI YPE OF Pt1MPl New 11Repair H P DEPTH PUMP SET FT FIRST WATER LEVEL fl © OUT-OF SERVICE WELL 11GEOPHYSICAL WELL F BOIL BORING 3 CI DESTRUCTION INTENDED U$E TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM OIA OF WELL EXCAVATION OIA OF CONOUCTOR CASING p ❑ DOMESTIC/MVATE ❑GRAVEL PACKISIZE TYPE OF CASINO/BTEELMVC OfA OF WELL CASINO d ❑ PVSUC/MUNICIPAL ❑DIOVEN DEPTH OF GROUT SEAL SPECIFICATION e ❑ IRRIGATIONIAQ ❑OTHER GROUT SEAL INSTALLED BY GROUT SRANQ NAME E ffo�ONTTORING GROUT SEAL PUMPED ❑Y. ❑Ne CONCRETE PEDESTAL BY DRILLER ❑Yoe (IN. S APPROX DEPTH LOCKING CHESTER BOX/STOVE PIPE �L S PROPOSED CONSTRUCTIONlDFSLUNQ 1,1E1H00 MUD ROTARY AIR ROTARY AUGER CABLE OTHER / tC 1 HERESY CERTIFY THAT I IfAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES STATE LAWS AND RULES AND REGULATIONS OF THE SAN JOAOUtN COUNTY HOME OWNER OR LICENSED AGENT S SIGNATURE CERTIFIES THE FOLLOWING I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH PERMR 18188UED (SIIALL N07 ETdPLOY PERSONS SUBJECT TO WORKMAN/COMPFN/LT1QN LAWS OF CALIFORNIA CONTRACTOR S FnRtMO Oq RAC TING SIGNATURE CERTIFIES OLLO CEfTTIFY THAT IH l'TIE PERFORMANCE OF THE tAlOFit FDR WHICH TH18 PERMR IB 188L1ED I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN 8 COMPENSATION LAWS OF FO A ANT MUa7 CA 21 HOUlL$ N ADVANCE FORA REQUIPtED IN/PFCTION/AT{3p/I ft/_a.I OMPLETE DRA OAT LOWER AREA PROVI EO 3 �y PLOT PLAN fO•.ev to Saafal Sada �l/ to ��._ I NAMES OF STREETS On ROADS NEAREST TO OR BOUNDING THE PROPERry / LOCATION OF HOUSE SEWAGE DISPOSAL BVSTEM OR PTIOPOSED S OUTLINE OF THE PROPERTY GIVIMG DIMENInome AND NORTH D1 CTIOH EXPANSION OF SEWAGE DISPOSAL SYSTEMS 7 DIMENSIONED OUTU Wff AND LOCATION OF ALL EXIBTWM AND P10Rq SED $ LOCATION OF WELL$VVrTWH RADIUS OF ONE HUNDRED FIFTY FT STRUCTURES BVCLUDING COVERED AREAS SUCH AS PATIOS ORVEWAYS AND WALKS ON THE PROPERTY OR ADJOIHI M PROPERTY • II v -i - IL DEPMTMENT USE ONLY APOIie.ttan Aveapl.d of D.r. G•eut Inay.elle By Oat. i3.•+/I—pseti—By D.1. D�r.IN�tlan Irwp.ctl.n By Q.t. C emm.nl. 3 7 ^' ^PUNITING ONLY /A,D/ FACE CODES FEE INFO AMOUNT RIPATTED CHECK$ICASH RECEIVED BY DATE Fg"TTSERVICE REQUEST NUMBER INVOICE a4�aSb /5- Pub 4eahh Sery ErtVlro 173(1/97)