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APPLICATION FOR WELLIPUMP PERMIT —SAN JOAQUIN COUNTY PUBLIC HEALTH SERV&...-, ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN 209)JOAQUIN ST., STOCKTON, CA 96201.388 Fly (209) 488-34200 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMJE/NTT�TITLE, CHAPTER 8-111(5...33 JAND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. N JOB ADDRESS/OR(APN.F r/Jl'l ��/�I. ��/�I ©I"'J�/C1 ,ry CITJY,y �)Lo r qT,TY.L /J PARCEL SIZE/APNO *jV 4 `� OWNER'S NAME S l�P/�� ✓• `A/C�IkW IMA.) ADDRESS 401/ y(ALU �V��~L PHONE♦ CI CONTRACTOR 1 i r IV ADDRESS 2f'`7 . ChAr f r' UCY 7 , ! PHONEY _* SUBCONTRACTOR ADDRESS UCN PHONE' TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL a_ ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRASS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL' ✓ ❑Now❑Repair H.P. DEPTH PUMP SET-FT. FIRST WATER LEVEL O C RYPE OF PUMP( ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELLY ❑ 601E BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS a A 13 INDUSTRIAL ��❑�OPEN BOTTOM DIA.OF WELL EXCAVATION + DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE GRAVEL PACK/SIZE TYPE OF CASINGISTEEUPVC G',^T�y� DIA.OF WELL CASING yF D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL /017) SPECIFICATION C R F �❑-,/RryQ1CfIONIAG ❑OTHER GROUT SEAL INSTALLED BY Y- GROUT BRAND NAME�A/ �II�1��1� A( ((MONITORING GROUT SEAL PUMPED: s 0N CONCRETEPEDESTALBYDR)LLERY�Y.. [IN. S r APPROX.DEPTHLOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONIDRILUNQ METHOD: MUD ROTARY ✓ AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAGUI 0 HO OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHA EMPLOY E N6 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: D RTI H\ IN T OR E jHE WOR(FOR WHICH THIS P RMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." C 1 MUS C 1 ND A CE FOR ALL REGUIRED N P TION A 1 1I 23. P D WING AT LOWER AREA PP.OVIDED. Slerrtl% ` Tit]. IDau KOT PLAN(Draw to Scale)Soals "to 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 6. 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. PAYMEW SEP 2 9 1995 l rvlu iui r DEPARTMENT USE ONLY V�1 '/ y �1 2 Application AEEaptW BY Data 1' L U I AA,.Grout Iropotl eon By Data -M 'fL Pump Iropection By Data Deatruotlon Iropmtion BY Gete Commenu: Y'0 L S Q�'t�� ACCOUNTING ONLY: AID' FACT PE CODES FEE INFO AMOUNT REMITTED HEC /CASH I RECDVED BY 1 DATE PERMITISERVICE REQUEST NUMBER INVOICE 58 2� �