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�. APPLICATION FOR WELLIPUMP PERMIT ; "AN JOAQUIN C;DU?gY;.PUBLIC HEALTH SERVM&E ENYIRONMENTA HEALTH DIVISION P.O. 13OX 388.304 EAST WEBER AVENUE. STOCKTON, CA 3528 9199 12091460-3420 SAN.O/+vU(N OOUgop NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PUSLIC l EALTH SERV (Complete ITripGc*t61 tNVIRONWt,ITAL HEALTH DIVISION R APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-111 S.3 AND THE STANDAP-08 OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. PARCEL SIZEIAPNI JOB ADDRESSOR APNO 1 �(�� r4. i�� LT J CT/ 43I 0lJC.7 IV OWNER'S NAME I/v��SG> Q�L I� AOORESS /L:f7 i?r^ � -� ` Z PHONE of 010 y 11-SN -2 ( 1 ADORESS32 ,��C n'iJYs:2a 5'`l/ Ur"(2E- CONTRACTOR V � � `�I L ADDRESS UC1 PHONE l SUS CONTRACTOR TYPE OF W_ELLPl1MP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL R ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 1 ❑NtT.v❑Reo,ir N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL. O (TYPE OF PUMP) �SOIL SWUNG 8 ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL' ❑DESTRUCTION: A INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS I/ ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION S DIA.OF CONDUCTOR CASINO R O ❑ DOMESTIC/PItlVATE ❑GRAVEL PACXIBRE TYPE OF CASING/STELTJPVC , R INA.OF WELL CASING D ❑ PUBUCIMUNICIPAL ❑OUVEN DEPTH OF GROUT SEAL ��/ SPECIFICATION ///J 8 �[=ATIOHIAG ❑OTHER GROUT SEAL INSTALLED BYv�/} GROUT BRAND NAME n -, E ORINO GROUT SEAL PUMPED' ❑Ye, ❑NO CONCRETE PEDESTAL BY DRUAR:❑Yr ON' S �O I LOCXN 'r G CHESTER SOX/STOVE PIPE APPROX.DEPTH PROPOSED CDN*TRUCTONRNVLitNQ METHOD: MUD ROTARY AIR ROTARY AUGERCABLE OTHER 1 HEREBY CERTIFY THAT 1 HAVE PREPARED TN1S APPMATION AND THAT THE WORK 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:'I CERTIFY THAT IN THE PERFOIMMAHCE OF THE WORK FOR WHICH NOT EMPLOY PER90N*SUBJECTTO WORKMAN'S COMPENSATION LAWS OF CALIFORNU.' CONTRACTOR'$HMINO OR SUB-CONTRACTING SIGNATURE CERTIFIES THIS]PERMIT IS ISSUED,1911ALL THE FOLLOWING: -I CERTIFY THAT IN THE RMANCE OF THE WOPK FOR WHICH TH19 PERMIT IS ISSUED'18NALL EMPLOY PERSONS SUBJECT TO WORIONAN'S COMPENSATION LAWS OF CALIFORNIA I THEA T CALL 4 HOURS TN ADVANCE FOR ALL REOUIRED INSPECTION*AT12206611 461J42l. COMPLETE DRAWING AT LOWER AREA PROVIDED. TItI. -2O /u Signed X PLOT RAN 01—to 9-61,1 9e,Ie 'to 4, LOCATION OF HOUSE SEWAGE DISPOSALSYSTEM OR PROPOSED 1. NAME OF STREETS OR ROADS NEAREST TO OR BOUNDWO THE PROPERTY. EXPANSION OF SEWAGE DISPOSAL SYSTEM*. 2. OUTLINE OF THE PROPERTY.GIVANT OWERMNS AND NORTH DIRECTION. i. LOC OF WELL*WITHIN MONS OF ONE HUNDRED FIFTY FT. 1. DIMENSIONED OUT tNFS AND LOCATION OF ALL EXISTING AND PROPOSED .--... -- ON THE PROPERTY OR ADJONSTG PROPERTY. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ww ._ .. DEPARTMENT USE ONLY AvPacatlen Aa ted ByD,te / 2- G#" Grout In,peetlen By Oete Pu-v In,peetlen BY DNe 0—tn.11—I—p—tien By D,te ACCOUNTING ONLY: AID/ FACS PE CODE.* FEE INFO AMOUNT REMITTED CHECX>//CASH RECEIVED BY DATE P9VMIT/SFRVICE REQUEST NUMBER INVOICE D Z Pub.Health Serv.-Enviro.173(3/96)