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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cal"pleff lei APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCTANDI`Oge NSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WTT11 SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN CO`UN)TY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH LNVISION. JOB ADORE99/OR A'PIm# , Y W t IT L'a y 5 ) /.{k r C,LLTY J5' I c �; }C:\ PARCEL SIZEIAPNI �j OWNER'S NAME ✓ // C yt5�'N Ll C e Q r') ADORE BB G / � 5 *L r PHONE f 11i CONTRACTOR [i`(]Ll l- L�G G N f 1 IA y 1PY1 1 ' L N C ADDRESS H'1 V�7 �' w ti t-1 W,.� til UC/6�C e,l 7 PHONE I-I E ,i 1 SUB CONTRACTOR FF** ADORE88 LIC/ PHONE/- TYPE OF WELUPUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J !T YPf OF PUMP) ❑N—❑Ro ol, H P DEPTH PUMP SET FT. FIRST WATER LEVEL77 p ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL/ Ipl ROIL BORING t I t 7 9 ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION /�'/) DIA.OF CONDUCTOR CASINO �" p ❑ DOMESTICAPRIVATF. ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO p ❑ PU1!IUC/MUN1CIPAL IAOMVEN DEPTH OF GROUT SEAL - SPECIFICATION r� R ElKO MINIGATN/AO ❑OTHER GROUT SEAL INSTALLED BY I P t M vt T- GROUT BRAND NAME_rl;: j G K c, E U1 MONITORING GROUT SEAL PUMPED; ❑Y— PH. CONCRETE PEDESTAL SY DRILLER:❑Yr ❑Ne 5 APPROX.DEPTH -`7 N I y / y LOCKING CHESTER BOX/STOVE RPE } I- S PROPOSED CONSTRUCTIONfMLLINO METHOD! MUD ROTARY AIR ROTARY AUGER CABLE OTHER t C I 1 RE-WRY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE M ACCORDANCE WTTN BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES ANO REOULATIONS OF THE SAN JOAOURH COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CEITTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEFURTT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIONAN'S COMPENSATION LAWS OF CALIFORNIA.* THE APPLICANT �MUST /JCALL 24 HOURS IN ADVANCE FOR ALL REOUMED{�.INSPECTIONB AT(120811/40-?422. COMPLETE DRAWING AT LOWER AREA PROVIDED. C, TRH. (I•r C�:; �i� V�'�I 1�7 / Dole 171,- , 1,- 1 �a q h 5 Aeoevted By DEPARTMENT USE ONLY -�E�1p.lbn � � G/ �- OrwA Im Det• By _ A— oeetlen (% �.�, 9 Dole P—P Imvxtlen By Oea D.wtnretlen Im ql vy v-zr CJYj1 b S /1 a� o C wI'l Q rss b S �c r s ACCOUNTING ONLY: AID/ FACS PE COOES FEE INFO AMOUNT REMITTED CHECK//CASH RE y T 181 T/SERVICE REQUEST NUMBER INVOICE l �I'J 2 J t