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&LICATION FOR WELLJPUMP PERMIT• SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED rt lJ (Complete In Triplicate) APPLICATION IS 14ERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF 8 JOAOUIN COU Y PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR API' 'TC / .S. II / /T �/t CITY R'F7'A`dr �F PARCEL SIZVAPN9 @ I OWNER'S NAME ../r— �( 1 e, 1 ADDRESS / P-W, PHONE' 1� k:: CONTRACTOR / �QIT/�� ICCfT�QI-L'-'y � V AODPE88 O Br/E F�+ &0414- UCI�PHONE/ 9 i T BUB CONTRACTOR ADDRESS (ICI PHONE• TYPE OF WELUPUMP: 11 NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER [7 INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION JWEELLL# SL✓�/ El New 11RepairH.P. _ DEPTH PIMP BET 9©FT. FIRST WATER LEVEL /L/ IT YPE OF RUMP c!* ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL' ❑ COIL 800IN0 g v' ❑DESTRUCTION: \1 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION& A p❑ IINNLJU6iMAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O f /� ODOMEBTIC/PBIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEEJPVC DIA.OF WELL CASINO D ,V ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROW BRAND NAME E ❑ MONITORING yly GROUT SEAL PIMPED: ❑ (IN.Na CONCRETE PEOEBTAI BY DIALLER:❑Vr ❑No 5 S APPROX.DEPTH !is 7' / LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONSTRUCTION/DIMMING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE9ESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PIVORMARCE OF THE WORK FOR WHICH TIHI6 PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'tl HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES(�" THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSON$SUBJECT TO WORKMAN'S COMPENSATION LAWS OF 1.1� CAUFORMA.' THE APPS 1T(AUST CALL 24 HOW IN ADVANCE FOR ALL REQUIRED ISNNIIPIECTION&AT(2001 4UJ 22. COMPETE DRAWING AT LOWER AREA PROVIDED. Money X _ I d I— TIG. Data "i''3 —r3 POT RAN IDray.to postal Goal. le 1. NAMED OF STREETS OR ROADS NEAREST TO On BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF TINE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES 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 WAL(S. ON THE PROPERTY OR ADJOINING PROPERTY. ....: ... .. ... i... ._. .... i. .! .. } Q 3 1 } iN s 'j-) L� :MAR 1998 t; . r 1/ LNTY. .. . 5IG I Lc,f VICES L it ,.� 1 n�ncF 47 UIVISIOI+ : I DEPARTMENT USE ONLY Application AcaeoteJ By Data Mu Grout Irepec0on 0, ate Rmp lmPrtloP BY :1 Data Oeaotvllen Imprtlon ey tData ACCOUNTING ONLY: AID# FACT PE CODES FEE INFO AMOUNT REMITTED HECK CASH RECDVEO SY DATE PEAMITISERVICE REQUEST Numalft INVOICE Pub.Health Sew.-Enviro.173(1/97)