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3(0 APPLICATION FOR WELLJPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON, CA 95202 (209) 468-3420 I1011•REFUNDADLf TERABIT EXPIRES 1 YEAR FROM DATE ISSUED ICempiete in TrBplient$) APPLICATION IS HERE BY MADE TO THE-SAN•JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOMA INSTALL THE WOW DESCRIBED.TRIIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELO /T rCHAPTER 9-1115.3 AND THE BTANOARDS OF BAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORE88IOR APN/' CITY y PARCEL SREIAPMI - - r - / ' V OWNER'S NAME AOORESS ,,CL.A/Y44-94... PHONE I t s CONRACTOR GI+ JCI PHONR5?' ,-L / �F SUB CONTRACTOR ADDRESS LICI PHONE I TYPE OF WELLAMMF: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONRORINO WELL 4 ❑ OTHER G7-Df ALLATKIN ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J ©New❑PW* H.P. DEPTH PUMP B$r/,2B FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OVT-0r SERVICE WELL ❑ GEOPHYSICAL WELLM 13 SOB.eORNO 8 ❑DESTRUCTION: INTENDED Usk PE OF CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O 1 ILYDOMESTICIPRIVATE ❑GRAVEL FACKIBRE TYPE OF CASINOISTEEUPVC DIA.OF WELL CASINO 0 13 PUBLFCIMUNICIpAL ❑DRVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRKRATIONIAG ©OTHER GROUT SEAL INSTALLED BY GROUT BIND NAME E CI MONITORING 'J GROUT SEAL PUMPED: ❑Yr ©Ne CONCRETE PEDESTAL SY DRILLER:©Y« ❑Ne S APPROX.DR7TH LOCKING CHESTER BOWSTOVE PIPE S PROPOSED CONSTRUCT10NIDRLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HE9E9Y CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORT(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATION$OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUDJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIER THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1$HALL EMPLOY PERSONS SUBJECT TO WORKMAN'e COMPENSATION LAWS OF CALIFORNIA.' THE AP NT MUST CALL24JWURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS AT 1209140BJI4". COMPLETE DRAWING AT LOWER AREA PROVIDED. G ^, $4n.d X _ Tltle �il.�� Date PLOT FLAN ID.ew to Selo Samoa •to 1. NAMES OF STREETS OR MAIDS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUrtP*OF THE PROPERTY,GIVSRG DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 9. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURE$,INCLUDING COVERED AREAS SUCH A$PATIOS,DRIVEWAY$,AND WALKS. ON THE PROPERTY OR ADJOWIrW PROPERTY, : 1 .. .` M (y} I El E7 ENT USE ONLY fI r1 Applle.11en Accepted 8'. �` ` V� Dote l Mr l t1.Pu1 b"PeeNen BY Dote Pump IrwPeetlen BY Dote / -�✓ 13-1 nalbn Impeel7bn BYE�++p n Dote an ( ^�� Cmant.: 7"Z3`i ` jDpf� i� ACCOUNTING ONLY: AIDE FACE PE CODES FEE INFO AMOUNT REMITTEDC /CASH RECEIVED BY DATE PERMITIeERVICE REO)U�E,,S/T NLIMMER INVOICE i 0`-'' ocaHtECK 7 1 I10"l Pub Health Serv. Enviro.173(1/97)