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APPLICATION FOR WEL PUMP PERMIT MIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NOR-REFUNDA9tE PERMIT EXPIRES i YEAR FROM DATE ISSUED (CempNls M TTlpfkalSl APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORT(DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE NRTIi SAN JOAOUIN COUNTY DEVELOPMENT TTTLE.CHAPTER 8-1 115�F�8T/ay.Agp�+Fl C�.►jZAAU1N COUNTY PUBLIC HEALTH SERVICES,SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AODRESS/011APNS I�5' �O /fj �Q/,'' ��Q� J�Gd�1Y'jCITY LiA/bE� PARCEL8tZFJAPRI OWNER'S NAME ADDRESS i6Z'19 C. PHONE CONTRACTOR ADOREBS /bZ5'9 E. /1K/Y Z& IJcs T'HoNE I(z,9`1)93/-/751 SUB CONTRACTOR , ADDRESS UCS PHONE S TLF`WEmmmp-., NEw WELL ❑ REPLACEMENT WELL ❑y MONrtowNO WELL I ❑ OTHER ❑ I1,19TAUATION ❑ WELL SYSTEM REPAIR IL CROBB-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J ❑Nave❑now, H'P' DEPTH FUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-0F•SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ son.BORING 9 ❑DESTRUCTION: "J INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM THA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO 0 ❑ oome9TICNRFVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEEUPVC DIA.OF WELL CASING O ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ 1 NGATION/AG ❑OTHER GROUT SEAL$"STALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: CI Yr ❑Ne CONCRETE PEDESTAL BY ORILLER:[1Y. ❑Ne S APPROX.DEPTH LOCKING CHESTER BOX/BTOVE PIPE S PROPOSED CONSTRUCTIONMAIL IND METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE9ESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL SE DONE IN ACCOF OANCE WITH SAN JOAQUIN COUNTY.ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUM COVNTY. HOME OWNER OR LICENSED AGENT'S SIONATURE CERTIFIES THE FOLLOWMGe'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIO PERMIT IS ISSUED,i SHALL NOT EMPLOY PERSONS SUBJECT TO WORIWIAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIER THE FOLLOWNNO: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS BURJECT TO WORIDMAM'S COMPENSATION LAWS OF CALIFOTWIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQISRED INSPECTIONS AT 1240)4404123. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X Title Dote PLOT RAN 10tow to Saelel Sa-le '!e 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4• LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED Z. OUTLINE OF THE PROPERTY.ONMG DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3, DIMENSIONED OUTLINES AND LOCATION OF ALL EXWTIINO AND PROPOSED S. LOCATION OF WELLS WTTHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY on ADJOINING PROPERTY. t .:. A4-RVAOY.;- ..... .. .. :. - ... :. �Q►�' � 15'T1N . �Q!VARA ~NT RECEIVED Is GU1L71JIN COV'NTY:' MENTAL HEALTH$Cts DIV DIVISION PUB s . 2-& 3� , ENVf1�ON i 1 i r DfPARTMENT USE ONLY Appilo.tlen Aeeepted By. 03 Yveto�� Ase�� AWL-7 41 G'eul hMpeellan 91 Dote — –�swMlmpeetlen By Dote . De.tne:tlen Imneetlen BY Dole - Ce,nmerNr - ACCOUNTING ONLY: AIDE FACT FE CODES FEE INFO AMOUNT REMITTED HECK !CASH RECOVED SY DATE PE RMITISERVICE REQUEST NUMBER INVOICE Io 1 1 I 1