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APPLICATION FOR WELLlPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 l ROPUREFUNBAOLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompleto In Trlplleatvl APPLICATION 19 IIER$BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1119.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH DIVISION. JOB AODRESS/OR AP#Y�+ �L 1 CITTY� ��lj�-t1�-} ,,,/,� PARCEL SIZEIAPNI r p OWNER'S NAME S ! yLS+I�r=. __ obi ADDRESS `i�_SLLyS�l� E W00 p-t IC, p, PHONE N 3641 CONTRACTOR _. I / G f�OS S .... ADDRESS�u kJtl , LACI 730 PHONE'My- �- SUS CONTRACTOR ADDRESS LICK PHONE 0 +•elltlalYOa .r� .+ TYPE OF WELLMUMPt ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLN ❑ OTHER ❑ INOTAUATIO14 ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 0 J i ❑Now❑Repel, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D— I'TYPE OF PUMP) - P ❑ our- F-SER/'V�ICE WELL ,/� 11OEOPHYBICAL WELLF A © ROIL BORIN,.Oy R pfSTRUCTION:_/1 / -- - 5r—�"L�1F� I1 r.L-A at AJ_/J.t`Cf� -- - C,*,WL INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMESTICIPSVATE ❑GRAVEL PACKISIZE TYPE OF CAIIING/STFELIPVC DIA.OF WELL CASING D ❑ PUSUCIMUNICtPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION p ❑"IRRIOATTDNIAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E Z ❑ MOWfORNG GROUT SEAL PIMPED: ❑Y. ❑No CONCRETE PEDESTAL SY DRILLER:❑Yaa CIN. S APPA X.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT T HAVE PREPARED THIS APPLICATION AND THAT THE AM1I0PIC WILL BE DONE M ACCORDANCE WITH BAN JOAQUIN COUNTY 6RDINANCE9,6TATE LAWS,AND RULES O REGULATIONS OF THE SAN JOAOUIN COUNTY, HOME OWNER OR LICENSED AOENT's 91GHATURE CERTIFIES THE FOLLOWWO,'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WF TWO PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP'ENRATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUR-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF (� CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCI FOR ALL REQUIRED MRPECTIONS AT 92001404-3423. COMPETE DRAWING AT LOWER AREA PROVIDED, Sbned X,- .rSiF"T� �j/.�L.�^s�� ---- TtHe i PLOT PAN(Drew to Seala$Reala •to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOLV40 MO THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED l 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 9, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WttTRN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINIIG PROPERTY, .. ., . LL I xat p [r CLC. . C: PAYS. Ff ' JUN15 1998 SAN-JOAQUIN-COUNTI_- Y—... ... _ I'uBLiC HEALTH SERVICES (//�y�/ /� ,� DEPARTMENT USE ONLY AppReatlen Aavepled BY /,/ /1 rJ Dat* A," Grout Impm"n BY 12 Date Pu p Amt mtlen By bete Deatne:llan Inapectlen BY Data ^�7 Cemmenla• " I ACCOUNTING ONLY, AID► FAC/ ' PE CODES FEE INFO AMOUNT REMITTED CHECK05 bH RECEIVED BY DATE" 1`91MIT1SPAVICE REQUEST NUMBER INVOICE aD�H' U� b(r5(48' .� I