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APPLICATION FOR WELUPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES I ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NUN-REFUNDABLE PERMIT EXPIRES 1 YEAR fflUM DATE ISSUED I (Complete In TriPRc9u) , APPLICATION IS HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT 70 CONSTRUCT AND/OR INSTALL THE WOrW DESCIMBEO.711118 APPLI N N CE WITIt BAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,EN no MENTA EALTH 0 ON. JOB AbhRES9roR APNf p J GLt , [ CITY_ ��^j�[•'jar� j,�.�/„..,, PARCEL SIZEIAPTIf__�y/p!G'l CY pf�/'7 OWNEn'n NAME ,/ r 1� T, J fC. {�.� ADDRESS Ly ) Gt— # Z PHONE',J- "7 6 — /j CONTRACTOR r 11^1 .I } Jr, AODRE89 I. ?C2 Ld I I C,�1[- ticI PHONE f SUR CONTRACT*" ADDRESS LIC/ P110NE i TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONrTOR1N0 WELL f ❑ OTt1ER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CFW99-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL f J ❑New❑Kvnh IT.P. DEPTH PUMP Ott FT. FRLST WATER LEVEL O r1Y1`E OF PUMPI s� ❑ OVT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL f © ROIL BORING R �OESTnUCTION: 6 1 '4 vIll-re, ee INTENDED USE TYPE OP WE CONSTRUCTION SPECtFICAT10Ns A ❑ INDUSTRIAL ❑OrEN BOTTOM DIA.OF WELL EXCAVATION h1A.OF CONOUCTORCA9tN0 p ❑ DOMFSTIC"IVATE ❑GRAVEL PACKISIZE TYPE OF CASINOMTEEL/PVC DIA.OF WELL CASINO 1, h ❑ PUnLIC/MUNICU+AL ❑DRIVEN OEP1M OF GROUT SEAL SPECIFICATION R _.[[...� ❑ mRIGATIONIAG ©OT}IEn GROUT SEAL INSTALLED BY OROLFT BRAND NAME E 1t` ❑ MONITGRING anow SEAL PUMPEO: ❑Yee ©No CONCRETE PEDESTAL BY DRILLER:❑Ye. ❑Na S '^ APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE S PROPOSED CONST IUCTIONMNLUNG METHOD: MUD ROTARY AIR ROTARY AUOER CABLE OTHER I `_ V � I HV%IIY CERTIFY TIIAT 1 HAVE PREPARED THIS APPLICATION AND 114AT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUtN COUNTY OIIOINANCE9,STATE t AWR,ANO RULE AND((((...._,. RFOUPATIONS OF 111E SAN JOAGUl"COUNTY, HOME OWNER On UCENSEn AOENT'B SIGNATURE CEITTIFIES THE FOLLOWING:'1 CERTIFY 7HAT IN THE PERFORMANCE OF THE WOtlK FOR WItrC11 THIS PERMIT IR tSRUED,ISOIAI.L NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORMA.' CONTMCTOn'R IItNNG OR SL76-CONTRACTING SIONAIUnE CEIT1111E8—• THE FOLt0 WNG: *I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMrr 19 IB9VED,1 SHALL EMPLOY PERSONS SUBJECT 70 WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' T APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRSD INS DNS AT 12Mt Ads-942!, COMPLETE OnAWING AT LOWER AREA PROVIDED. [[ Rlsnwd X �'C.-L' TRIa a lf' PLOT PLAN tMow to Be�lel Beal• -L.w 1. NAMER OF RrRF,FT R ROADS NEAREST TO OR ROUNDING TIIE PTIOPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL RYR7EM on PRhP09FD i. OVILINE OF Tiff PROPERTY.GIVINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. C4� 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED E, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, RTnUCTUnEB,INCLUDING COVERED AREAS SUCII A9 PATIOS,DIBVEWAYS,AND WALKS. ON TILE PROPERTY OR ADJOINING T7IOPERTy. T. -�-r. :Ir,�.�y6.-er C"r.r.C-rc Ic.. : ... :. _a_ OR ) t7titf .lM�:.. .A/rx lT3.. irf<�N.LL S :. JUN 3 99 .. SAN. Az:atTrl r — — �f Ih=7s-I /tet � FAIT 4 �BNRi DEPARTMENT USE ONLY Date G,e�,11n.eMrten Ay ./11JL.C.�k bafe y' - P1ae.n rn.Peeaen by D.1a f Der.ln,n�len Imnaellon By m fit• �„,„ -_ . 4 oA 44� ACCOUNTING ONLY: Algf FACE PE CODER FEE INFO AMOUNT nEMIT1E0 /IEC ICAn11 RECEIVED BY DATE PU MITISERVICE IIEOUEsT NUMBER INVOICE j aU Pub.Health Serv.-r=nviro.173(1/97)