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IK APPLJ0N FOR WELLIPUMP PERMIT SAN JOA. ;OUNTY PUBLIC HEALTH SERVICES ENVTt.40IMENTAL HEALTH aIYISIOH ., P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON.CA'9520VW-; 12091468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEd;j,,f ICDmpkd In Triplkaul 28 APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRI SEO.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN 1OAGUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. OB ADDREBSIOR APN//y_�ELT Y� S 1 n n Q f\l'J� CITY PARCEL SREJAPN/ OWNER'S NAME 1 1 1 Q A to @. I 0 ns�� ADDRESS S�JQQ�!I�.. PHONE• q y CONTRACTOR r'� t e. !G ADDRESS UO C-Y.537bg PHONE ^-'CO 11 UB CONTRACTOR �� ADDRESS LICE ^ PHONE f I (TYPE OF WEU./PUMF: 11NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL E ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL 0 J CI Naw 13 H.P._ —1 DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) peP!qGyf}❑OUT-OFSR:RVICE WELL ❑GEOPHYSICAL WELLR ❑ SOIL BORING 8 �I ❑DESTRUCTION- R INTENDED USS TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑,--�INOUBrmAL 13EN OPROTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTORCA91"O O lb'DOMERTICRRIVATE ❑GRAVEL PACK1917F TYPE Or CA91NO16TEELMVC DIA.OF WELL CASINO D ❑PUBUGMUNICIPAL ❑ONVEN DEPTH OF GROUT SEAL SPECIFICATION A ❑IRRKUATKINIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME £ ❑MONITORING GROUT BEAL PUMPED:E3 Y. [IN. C004CFIETE PEDESTAL BY DRILLER:13Y. []Na S I' APPROX.DEPTH LOCKING CHESTER BOXJSTOVE PIPE S PROPOSED CONETRUCTIONIOPDWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HF9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REOULATIONS OF THE SAN JOAQUIN COUNTY, NOME oWNER OR LICENBFD AGENT'S SIGNATURE CERTIFIES THE rDLLoWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH 1 THIS PERMIT 40 ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR BUB-CONTRACTIND MNATUIIE CERTIFIES 1i THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB IBRUED,I SMALL EMPLOY PERSONS SUBJECT TO WORIUTAN'e COMPENSATION LAwd OF CALIFORNIA.' T ANT MUST CALL Z4 MOURS IN ADVANCE FOR ALL REQUIRED INS TIONS AT 4"114"4421,C�MPLUETE�DRAAW�I�NG AT LOWER AREA PRD DED. 'BIen.4 X Tltl., r�1C/LL7�TLV��+•+F+'L"-� Da7• PLOT PLAN ID,—to B-I-I B"It Ua It.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4, LOCATION OF HOUSE SEWAGE D48POBAL SYSTEM OR PROPOSED Z.OUTLINE OF THE PROPERTY,GIVING DFMENBIONa AND NORTH DIRECTION. EXPAN810H OF SEWAGE DISPOSAL SYSTEMS. 7.DIMENPONEO OUTLINES AND LOCATION OF ALL EXISTMO AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FI. 1. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS.AND WALKS, ON THF PYIOPFRTY OR ADJOINING PROPERTY. ... .., `.. . ... .. ... .. . . .... ....,.. :. .. Nau-se ILL :, . 1. I JUw1 3199f PUBLIC HEALTH SERVII cS LrtlVml��ilEIVTFlL H�ALTF{DflrjSf()N 1 DEPARTMENT USE ONLY ( APPlio.tlen Aaeapted BY Det. - ct J6 Arr 1 Oreul Irrl..ellen SY D.fe Pump Ieep 11-BY DMe C�! J KI Oann�tl.n Imp. 1-SY D,t. . I Cemme,rt.' I , ACCoUNTINO ONLY: MDR FACS FE CODES FEE INFO AMOUNT RBM TED CNEC !CASH RECEIVED BY DATE PERMITIIEAVICE REQUEST NUMBER INVOICE 1) I� I