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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERV-aS PAYMENT ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAOUIN ST., STOCKTON, CA 95201.388 RECEIVED (209) 488.3420 J A N 0 5 1016 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM OAT E ISSUED SAN J©r r tiUIN WONTY (Complete In Triplicate) PUBLIC HEALTH SERVICES APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APEPNIJCA�YTbN'IBZ.1N��IN tT1A ANC W17N BAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNNTTY.PUBLIC HEALTH SERVICES,EENNVIROONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN# J J / I CITY V/OC��yL n' ' LJ5 PA92E�EL SIZF/APN# OWNER'S NAME Q W ! �/V 4 ADDRESS `y 3 9 �'�'{t L1 f u vq J.�� PHONE i �v1 ' a q CONTRACTOR S ADDRESS 1 O /1 �9 2,_UCi Ib231pR)NEIRY�e-9czr SU8 CONTRACTOR ADDRESS ny� Il� /-FL ��I� ILICi PHONE# TYPE OF WELUPUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# 1-•`� ❑ OTHER , ,/INSTALLATION �, WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J Je lL9 Rev❑Repair H P.�_ DEPTH PUMPSET 2 OFF FIRST WATER LEVEL E D RYPE OF PUMP) — ❑ OUT OF SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEE4 C DIA.OF WELL CASINO D - ❑ PUSUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Y. ❑No CONCRETE PEDESTAL BY DRILLE11:❑Y. [IN. S - APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DIBWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THI6 APPLI IT N AND THAT THE WOW WILL BE DONE IN ACCORDANCE WH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HO O ER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS MItAIMMON,I SHALL NOT EMP P P R NS S BJECTTO WORKMAN'S COMPEHSATI LAWS F CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING E'x/.'I'v' THAT N P RAR CE OF THE WOW FOR WHICH TI�1 RMIT IS ISS)ED I HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' �I�'P CMiT MUT ,B�.pW/�/ MMRED 1 iPECTI�e=T 1 DJiw31. COMPLETE DRAWING AT LOWER AREA PROVIDED. Q G SISrW% V —�/ TRIe //11 L✓✓l Data I —J /V PLOT PLAN (Dr.to Gula)SmIa�G46� 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE 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 WAI ES. ON THE PROPERTY OR ADJOINING PROPERTY. N W'd iw 4- ------------- , yAA .N? . AN 81ggc M DEPARTMENT USE ONLY APplimtion Accepts BY '` Dab Area G'..Irapection By Dum ate Pp Im1.etloD By Dab L D.truction Irol.ctlon By DFL ComrrI.w ND n/� .Kl�icn ACCOUNTING ONLY: AID# FAC# PE CODES FEE AMOUNT REMITTED C EC ASH RECEIVED BY DATE PERMITISDRVICE REQUEST NUMBER INVOICE 1 -1\> S