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r APPLICATION FOR WELLIPUMP PERMIT `3 "'SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIM L L ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-388 V (209) 468.3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompMEP in Triplicate) ` APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALLTHE WORK DESCRIBED.THIS APPLICATKIN IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT ,CHAPTER PT9-1115.3µD MHE pA7 OF SAN JOAQUINCOOUN Y PUBLIC HEALTH SER CES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORESS/OR APNI In •�J(,'XJ I PARCEL SUWAPNF 1, ` OWNER'S NAME i { NE i U' S p coNTAcroa ADDRESS --I• `� + .uc;r U NEs_ �1 SUB CONTACTOR ADDRESS LIC# PHONE TYPE OF WEWPIIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER Cl INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL i ❑Nc ❑R. lr iii DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMPI /1 O -Op-SERVICE WELL ❑ {FEOPH SICAL WELL• 11 ❑ SOIL BORING S JUWESTRUCTION: ,,Cull L f 1 �J/1 1 �- 11 ' "•••///INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS L ❑ INDUSTRIA ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING ❑ DOMESTIC/PRIVATE ❑GAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING _ ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME r ❑ MONITORING GROUT SEAL PUMPED: ❑Y. ❑No CONCRETE PEDESTAL BY DRILLER:❑Y. ❑No S APPROX.DEPTH LOCKING CHESTER SOX/STOW RPE 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"AMIN COUNTY ORIXNANCES,STATE LAWS,AND RULES AN REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOWC FOR MIC THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAIJ INIA.' CONTRACTOR'S HIRING OR SU"ONTACTING SIGNATURE CERTIRI THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOW(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS� } C IA' T APPUCANT MUST C M HOURS IN ADVANCE Fon ALL REQUIRED IN RECTION{AT 120111468-]425. COMPLETE DRAWING AT LOWER AREA PRO SlPmd x J 1 �,�� Tltla / .! D4N PLOT PLAN ID,..v to Sc.l.l Sul. 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 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 OMUNFS AND LOCATION OF ALL EXISTING AND PROPOSED 5. 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. !- KeD 6TE I r.