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CPPLICATION FOR WELUPUMP PERK Uas C �J6 SA. JOAQUIN COUNTY PUBLIC HEALTH SE._/ICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON REFURBABEE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Mompisis I APPLICATION IS PICK BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.11118 APPLICATION IS MADE IN COMPLIANCE WRII SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAFFER 9-1116-3 AND THE STANDARDS OF SAN JOAQUIN COUNTY MBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN/ ` p- /3 I 6� 1:I44 n S en !�+�CITY /�•4 G 4 PARCEL SIZEJAFD# OWNER'2 NAME Fre-, r J sy (0- J II / n - ADDRESS MONEI G CONTRACTOR I rI-, -J,:� C / - . ADDRESS / V nTT,y S� �2 PHpNEI C�QIy PUB CONTRACTOR ADDRESS LIC' PHONE/ TYPE OF WEL4PLIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER CC ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR VR EXTRACTION WELL/ J� 10 11APO ❑Nsv❑Ft".Ir H.P._L DEFfH PUMP SET_FT, FIRST WATER LEVEL _ (TYPE OF FVMPI R 14 c.'ement- ° ❑ OUT OF-SERVICE WELL ❑ GEOMYSICAL WELL I ❑ BOIL BODING S f\� ❑DESTRUCTIONS �/V INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A Q r❑ I/Np}1STRIAL 13 Oren BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D LJDOMESTICRAIVAT E ❑GRAVEL PACKISIZE TYPE OF CASMO/STEEU'VC CIA.OF WELL CASING D ❑ FUBLIGMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SFECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME EZp ❑ MONITORNG GROUT SEAL FUMIRD: ❑Ys 11 No CONCRETE PEDESTAL BY DRILLER:❑Yro CIN. S r' APPROX.DE"N LOCKING CHESTER BOXJBTOVE RR S S PROPOSED CONSTTMUCTIOMIDFBLIJNG METHOD: MUD ROTABY AIR ROTARY I AUGER CABLE OTHER - I HEREBY CERTIFY THAT I HAVE PREPARED THIS AD (CATION 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 AGEM'8 SIGNATURE CERTIFIES TIIE FOLLOWING:'1 CERTIFY THAT IN THE FERORMANCE OF THE WORK FOR WHICH 11118 PERMIT IB ISSUED,I BIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMFENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORE FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORXMAN'S COMFOISATION LAWS OF SI,L 1 XNIA.' TNF A CALL yt�o'IgUq� ^AN TIU. 10V_Ai ONS wu 11SB�}EX�COM NG AT LOWER DHaAREA PigVl 3 r) 9/1^IL(1 MOT MAN to,—le BeN.I F' 1, NAMES OF STREETS OR SCADS NEAREST TO OD BOVNDING THE PNOMSTY. S. LOCATION OF HOUSE SEWAGE DISFUSAL SYSTEM OB F OMSED Z. ONLINE OF THE DBOPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISIOSAL SYSTEMS. D. DIMENSIONED OUGLINfe AND LOCATION OF ALL EXISTING AND PnOPOSED S. LOCATION OF WELLS WITHIN RADIUB OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,AND WALX9. ON THE PROPERTY OR ADJOINING PROPERTY, 0 IIOJwE+iP �ob;1e. a( qnp Ho45 SZ Q V 4 N SOS 7�0 h P'L�.'�'6�EN pol REGEIVED AUG 51997 SAN JOAQUIN COUNTY '1 PUBLIC HEACES LIHEAEENH ID V SI(Ml DEPARTMENT USE ONLY ZAoolle.11nn Aeeeplwl BY � 0.1. b.. GIL _ Gmm b.P.elb By DN. Pump In.nroBen By DroDlbBen In.nronen 0r D.l. C.—at".: ACCOUNTING ONLY: AID/ FAC/ BE CODES FEE INFO AMOUNT REMITTED CHECK' ASH RECEIVED BY DATE PEDMITpFRVICE REQUEST NUMBER INVOICE r O/ a5 vo8zr, Pub.health Serv.-Enviro.173(1197)