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APPLICATION FOR WELLJPUMP PERF a- SAft.dOAOUIN COUNTY PUBLIC HEALTH Sa"-'IICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON, CA 95202 (209)468-3420 11011•REFUNpABIf PERINIT EXPIRE8 1 TEAR FROM DATE 18S Ep 1Comploto i8 Tri lket.) APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMA INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE MH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESS/OR APNI O O W/}. L.I>-d />r--ice CITY s 7-c> C-,r--rE:>tiI / /� � 1 PARCEL 812ElAPN/ OWNER'S NAME L � R TCS/-r ADDRESS o fA+ ,,j. PHONE 1'�a`3 6 98'7 CONTRACTOR I-+' ADDRESS S$S Amt C Q e_,j-D ucF � [f R —� ��'PHONE N !� 3��7-rlOt] SUB CONTRACTORS f"e6-'t P�.Q 9-A--1 � •"r G 4 S S3j ADDRESS 6 w t w L1CN PHONE! O b1f cr+ r IL- TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL t ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL J Now❑Repalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL {TYPE OF PUMPI O ❑OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL u ❑ SOIL GORING IR DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION ZIP IONS A INOUSTMAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASINO ❑ DOMESTICMRIVATE 11 GRAVEL PACKIBr2E TYPE OF CASING/STEELIPVC O DIA.OF WELL CASINO O ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yea [IN. CONCRETE PEDESTAL BY DRILLER:[3Y. ❑Ne 8 APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE S PROPOSED CONSTRUCTION/DRIWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 WWRY CERTIFY THAT 1 HAVE PREPARED THIS APPIJCATION AND THAT THE WORK WILL Be DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS 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 18 ISSUED,I SIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALN"ORNIA.' THE AP CANT MW tL 24HOURSIN ADVANCE FOR ALL REQUIRED 1NSPEC1Tows AT R2W 4ft--9422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Sturd X ' c'—- TIN. �.OS�G'T ..1" 'A-1,j A} tE 2 �. ,_•_,__Date PLOT PLAN Mraw to Seelel Scale -.'d 1. NAMES OF STREET8 OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANBION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXI8TINO AND PROPOSED E. LOCATION OF WELLS WITHIN RADR18 OF ONE HUNOREO FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, L_I�s A-CSS"D. '. . S . J ..............'...... :... .....:.. ..:.....[...,. ALA ..- ....-................... ........... .........,...... .. l DEPARTMENT USE ONLY �] �!+ APpticarion A99WIed BY - Dale Are. Greeff"pwilen BY Dete Ph p Inapeetren By Dete O"In den 1mpmtb/n�8y Date Cemmenta: csA�� Y L 1 S I4�T LJ - Y t"•�'�' `''� /S�L� T D ti� ACCOUNTING ONLY: AID$ FACT PE CODES FEE INFO AMOUNT REMITTED CHECK/ICABN RECEIVED by DATE PERMITIStKVICE REQUEST NUMBER INVOICE 2 a ID•3I � � Pub.Health Serv.-Enviro.173(1197)