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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) 458-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compltla In TripReala) APPLICATION IB HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE 9TANDARDB OF BAN JOAOL)IN COUNTY PUBLIC HEALTH SERVICED,ENVIRONMENTAL HEALTH DIVISION. e JOB ADDRESS/OR APNJ J ( -L.•1�2��T.iiy �iCITY PARCEL SI7E/APNP OWNER'S NAME � �QX�� 1�-� i'�.�"�-' ADDRESS �U�r PHONE'2(' l`1 v ' d. E) CONTRACTORy-�C.i[�C'� �Z[i/}+�� ,-1 Ab[NtE88 1 �_ (.,— /�LICJ (110NE J v Q OUR CONTRACTOR ADORE88 UCJ PHONE J TYPE OF WELLJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL J ❑ OTHFR ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL J ❑New❑flood, H.P. .� DEPTH PUMP 9EF_&CT. FIRST WATER LEVEL 0 (TYPE OF PUMPI ❑ OUT-OF-SERVK:E WELL ❑ OEOPIfYSICAL WELL J ❑ SOIL BORING g ❑APTTTTRRUCT11pE1- INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOME STKUPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASINO D ❑ PUBLIC/MUNICIPAL 1-1DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R 13-MRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY OT10UT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Ys ❑No CONCRETE PEDESTAL BY DRILLER:❑Yee ❑Ne 5 APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONATRUCY10NRNtlWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HE-WRY CERTIFY THAT I IIAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN't COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S Hinmu OR SUBCONTRACTING SIGNATURE CEITTIFIEB THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMfT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOPIKMAH'S COMPENSATION LAWS OF CALIFORNIA' THE A�PPLIICAy�N/T,FAUST CALL 24 HOURS IN ADVANCE /FOR ALL RFO�/-I"ED INSP*CC/1tMNNG,AT 12051 4q-:11423. COMPLETE DRAWING AT LOUVER AREA PROVIDED. /- BlOned X ��'Ww�c`2�•y-. !��4L�(i�/ .h TII� �'/i/-'c-!1.►� D.te �/� / II�� '�'y_�— L�J PLOT PLAN 1D,ew 10 8o1e1 Rode 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNLAPIG THE PROPERTY. 4, LOCATK)N OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED _ 2. OUTLINE OF THE PROPERTY,OIVWIO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIBPOM SYBTEMB. J. DIMENMNED OUTUNFS AND LOCATION OF ALL EXISTMO AND PROPOSED _ S. LOCATION OF WELLS WITHIN RADIUS OF ONE 14UNDMO FIFTY FT. 1� STRUCTUREB,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. J 1 " Cho r b- 1998 1998 SA;,.11 lLa{ ENLu VIRdINI EN7A kr-.-aETh�l?v16i11 _ I _ ........ _..__. U3¢ONtY --- — — ( Appkellrm AooePted By Date Mw ) Grout Imptlt lion BY Dete F`ump Inepeetion RY_ Dela S' iP-)— ne.v,ealen I...P-0—BY Dae Commnrrte: ACCOUNTING ONLY: AIDS FACS PE CODES FEE INFO AMOUNT REMITTED HE JICAAH RECEIVED SY DATE PERMITIaEAVICE REQUEST NUMBER INVOICE Puh HRedth SerV.-Enviro. 173 (1/97)