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APPLICATION FOR WELUPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 } NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TTIpDeStB) APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,yCHAPTER 9-1t1 115.3 AND T11447Ej STANDARDS OF SAN JOAQUIN COUNTY PUBLIC 14EALTII SERVICES,ENVIRONMENTAL HEALTH DIVISION.A JOB ADDRESWOR APN/ iL''L �-I 1/ $ �t[,vim ( ( CITY ZcLy4ea/2 PAARRC_L SIZE/APN/ fy m � �JSZ C_ OWNER'S NAME (L'VI ( ) -v-FI T TYAI�DDRRE'rSS- � �T7�vY PHONE CONTRACTOR �x�L.7JRTPY ��! /!/!CI ADDRESS]OL' J IZ,1 Sti.1'A^.7 UC/ a.i.?:-/.-?/,LC-PHONE/ let',7-X1 SVS CONTRACTOR ADDRESS LIC/ --PHONE/ TYPE OF WELLMUMP; ONEW WELL REPLACEMENT WELL ❑ MONITORING WELL At ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL f J ❑New❑Rep.1, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMPI ❑ OUT-0F-SERVICE WELL ❑ OEOP4IYSic Ast WWEELLLL# [/ �7 ❑ SOIL BORING q OOESTRUCTION: - -Fl t•(l i 1- (^i n iYhQ ill/P V"�'j+>I -TQ'/Y" INTENDED USE TYPE OF WELL d�-CCO�NST�RUCTION SPECIFICATIONS / A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION n�[ t DIA.OF CONDUCTOR CASINO/ D 0-DOMESTIC/PRIVATE OGRAVEL PACK/SIZE__ TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO T✓/ O ❑ PUBLIC/AIUNIC IPAL ❑DRIVEN DEPTH OF GROUT BEAL (VJ�v SPECIFICATION I W!J �S 1 R ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY /J 1-J Ile[ GROUT BRAND NAME P)eC U E ❑ MONITORING GROUT SEAL PUMPED: ❑Yom [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr I1 o S APPROX.DEITH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONtTRUCTION/DPILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HVIEBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH CAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND nEOUTATIONS OF THE SAN JOAOUtN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WMICH THIS PERMIT 18 ISSUED,I$HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENEATTON LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMMNSATION LAWS OF CALIFORNIA.' T POUC ANT MUST A 24 HOURS IN ADVANCE FOR ALL REOUMED INSPWCT)AS AT(2001 40SAM27. COMPLETE DRAWING AT LOWER AREA PROVIDED. 91prrd X n. TItI. -�.�J' jc- y� Da. . MJ1N(O's-to 8-1.)Be•I• 'to 1. NAMES OF STFIEFTS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PPbPOSED 2. OUTLINE OF THE PROPERTY,GIV*M DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WfTHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLVDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. oir OCT 2 3 199 aAr�, tGN,(r n�G{�LiPI� PUS!-Ji-HEALT ,SE:F-1VI ss.' S(r c7;'dIRO IvtEry7AL"I..ALT'H OSV.3i --�� 69 [41( a _ ►MTMENT VSE ONLY Applle•tlen A—pted BY 13-14,____/la A,..�^^/�D Mein Imp-11-BY Da. '�` R>rnp nspoctlen BY Date DMtn�ellen Inspect B Dot•/1��'-Z c n 13. 8 R7 ! BIL' + J L I �i9SrNG - 20 / (toN�T 17cr� ✓o l.6c�� { �r OvSC'9�G UOI.CC ✓} �2`/-} AN4�4up.�ulvG 78 wear w aR�aw a6a6-o -Alr A ACCOUNTING ONLY: AID/ FACS �� GSf'o,Vasup �Z INzo+l Bco�sw�c PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE PERMIT/SEANCE REQUEST NUMBER INVOICE sc 6 0 7 C)/ ;L o `% ✓ ' ;Z Pub Health Serv.-Enviro.173(1/97)