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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WE13ER AVENUE, STOCKTON. CA 95201388 (2091469-3420 MOM-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete I APPLICATION IS STERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCTANDIon INSTALL THE WOR(DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN/�4.q—Q��,7� ( w (/��--i�✓ t PARCEL SIZEJAPN/ I,QQ/�L/04606 )!L OWNER'S NAMEk �11�•1�} `IlQ� ADDRESS S( Pj(j�4 �-I LAI-e - I cAt O 1Z ( pH-ON/E f `7 CONTRACTOR�-�c.�TCLJI.n �1( [�A�L{r) ADDRE88Z�SkJ,4(,,�� S-LTLkkn..1 LIC�7S/Z2�Y SUB CONTRACTOR ADDRESS LK:/ PHONE/ TYPE OF WELLJPVMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J (TYPE OF PVMPI New❑Reo.lr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL ❑ may/ /OUT-OF-SERVICE WELL 13GEGF44YSICAL WELL/ 0 .11.BORING I B 1:1 DESTRUCTION: INTENDED USE - TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING A DOMESTIC/PRIVATE 11 GRAVEL PACK/81ZE TYPE OF CASINO/STEEL/ DPVC DIA.OF WELL CASING O PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED By GROUT BRAND NAME E MONITORING [� GROUT SEAL PUMPED: ❑Ye. [IN. CONCRETE PEDESTAL BV DRILLER:❑Yw ON. ,S APPTIO X.DEPTH_J�Q 7/9 LOCKING CHESTER BOX/RTOVE PIPE _ PROPOSED CONSTRLICTIONMI ILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE_ OTHERQIYi[t U.JSd� I HEnEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL Be DONE IN ACCORDANCE WITH SAN JOAOU,N COUNTY ORDINANCES.STATE LAW`-S.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWIN1:: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TITIS PERMIT 18 ISSUED,1 BITALL NOT EMPLOY PERSONS BUBJ O WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: ,1 CERTIFY THAT IN THE PERFORMA OF HE WORK FOR WHICH THIS PERMTT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' Cu b%THEA ANT MUST CALL 24 NO N AD NCE FOR ALL REQUIRED TIONS AT(2001460-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. SIg d X TItt. PLOT PLAN IDr to SeWI 8..1. to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROP06ED 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINF8 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. i < e>� 0. = DEPARTMENT USE ONLY Applie.tlon AeaeDltrd ByDat. / _Ar OroW Imp—d—By M ow P,—v Inapaetlen By Dat. Deatttretlen I—P-0—BY ,( eemmer,t.:dK-� d5,1U �2 0 llL L v - L.ctk ACCOUNTINO ONLY: AID# FAC/ PE CODES FEE INFO AMOUNT REMITTED CHECtoCASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE .o► aD d2i°:� God-��.b � lll� 6/ �l Pub.Health Serv.-Enviro.173(3/96)