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APPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAUUIN ST., STOCKTON, CA 95201.388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �"��71�j (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115..3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/09 APN# Q ��' ��/ /�)� �i� CITY �JL�LL)�� / PARCEELL}SIZE/AMR OWNERS NAME 'J.- yy� �q / `%< L ADDRESS ,�J! J�72' CONTRACTOR /�� 7C I // G. `� ADDRESS L2 L;� / L�/I�� 'UCe PHONEI /.dL_.JiJi) SUB CONTRACTOR �� ADDRESS UC# PHONE# TYPE OF WEL11PUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ( f✓J-e;k- ❑NewRepalr N.P. DEPTH POMP SET FT. RYPE OF PUMP) FIRST WATER LEVEL nC% � D ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ BOIL BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELL CON&TRUCTION bPECIFICATION& A ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO 0 ❑OOMESTICTRIVATE ❑GRAVEL PACKISRE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASING D ❑PUBUClMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑MONITORING GROUT SEAL PUMPED: ❑Ys [IN. CONCRETE PEDESTAL BY DmLLER:❑Yr [IN. S ANROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTION/meLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WELL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES, THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW(FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'&COMM UWB O CALIFORNIA.' THE APPLICANT MUST CALL 3.HOURS IN ADVANCE FOR ALL IRMUIRED SHIMMIES AT(2081488J.]f. COMPLETE DRAWING AT LOWER AREA PROVIDED. el'r X THE. Daa PLOT PLAN ID,.w m Sc.l.)Sul. 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED !�1 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. \_ 3. DIMENSIONED OUTLINES ANO LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,D VEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. !c CI, DEPARTMENT USE ONLY y Applica en Accwt.d By (4L 9 «uD.t. L.� Ara _ J Groh Impmtl.n By D.I.Dwmv In.von er D.I. d-f Y .1 D.trmtlan Imo«tion By D.t. ACCOUNTING ONLY: AID# FAC# IT COD" FEE INFO MOUNT REMITTED NEC CASH RECEIVED BY DATE PFRMITISERVICE REQUEST NUMBER INVOICE 3 y5.