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APPLICATION FOR WELL(PUMP PERMIT 0 SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (109) 468.3420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Tr(plicete) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCRIBED.THIS APPLICATION IS 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 ADDRESS/OR APNI "Y LDG CIT-1( Lod i r �,�nIPARCEL SIZE/APNI_ OWNER'S NAME J7(Y{/t f�s („7(il�jtYC ADDRESS pp < Q �� PHONE I�/9 CONTRACTOR��vn(e1 �S ADDRESSZff0_3 �/�JQ,(�h ��--A,;j0k;99IPHONESUBCONTRACTOR el L ADDRESS Q M ``� C/ N PHONE I h TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J New 11Repelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL R YPE OF PUMP) ❑ ry/ O OVT-Or-SERVICE #WELL ❑ GEOPHYSICAL WELL OO SOIL BORING e ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTgUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOMDIA.OF WELL EXCAVATION 2 ZS r I< DIA.OF CONDUCTOR CASING A D DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASING ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL_S ..iE.� SPECIFICATION_ 0 IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME W i/ E 14` MONITORING /�/� ,�/� GROUT SEAL PUMPED: [IY_ No CONCRETE PEDESTAL BY DRILLER:C1Yen &p No S APPROX.DEPTH 2 (G®t LOCKING CHESTER BOX/STOVE PIPE S PROP09ED CONSTRLICTION/DAILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REOULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SI{ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL HOU IN ADVANCE FOR ALL REGLIIRED INSPECTIONS AT 12021460-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED9 910ned X ,�1Tltle � nets Z//7 / ! PLOT PLAN(Drew to Seelel Solve 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROpOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION Or 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 WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. OIL I elk 1,16 All hoc ate �2 / DEPARTMENT USE ONLY AppIIcstIen Accepted By Date - •�� Area Grout Impectlon By Dete Pump Inepectlon By Data DeetnrUlen I—pectlon 13 `I n not. I f Commertu: II)rsc. - 3c4-✓l10L1✓L�i p1'tOt/((,(J Qpjqro\/gP o{ T,Q Lr_ to Of 1Nt7►^Kcye✓WIt Z'ZI Pe ✓ML,+ L550a.ncR cord.Lhoond DPA PH EH � bout of wor LA a_vvcn�G.✓Lc¢ �1 ACCOUNTING ONLY: AIDE FAC/ S:5 G 1 eLl `S A ss a 1""M 4 or►. �e PE CODES FEE INFO AMOUNT REMITTED CHECK#1CA9H RECEIVED BY D�AT PERMIT/SERVICE REQUEST NUMBER INVOICE �'-- 1 Pub.Health Serv.-Enviro.173(3/96)