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1 APPLICATION FOR WELL/PUMP PERMI- SAN JOAOUIN COUNTY,PUBLIC HEALTH SES, . 'ES ENVIRONMENTAL HEALTH DIVISION F�',O, SOX 388, 304 EAST WEBER:AVENUE, STOCKTON, CA 9520/388 12091468-3420 MON-REFUNDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Camplettl'In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WRH SAM JOAOUlN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN,A Ae'0 � CffY PARCEL SIZEIAPNf Q OWNER'S NAMETOG -rh.. ./� I G Y _ ADDRESS .20 PHONE,v3�� 4� `J CONTRACTOR __� 99 41 9 �^�� _ CGS `ADDRESS (j' LTCB,-y PHONE/'� SUB CONTRACT .v\ C � ADORES. s1 S CLICS pPHHD E sw52�-1-'Zf' TYPE OF WELLlPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL 0 11 OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL, RYPE OF PUMP, ❑New 13Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL tl ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL 0 ❑ SOIL BORING R ❑DESTRUCTION:- - - INTENDED use TYPE OF WELL CONSTRUCTION SPECIFICATIONS A INDUSTRIAL 13OPEN BOTTOM //�,�� LL DIA.OF WELL EXCAVATION- DIA.OF CONDUCTOR CASINO � ❑ DOMESTIClPRIVATE GRAVEL PACK/SUE—e-Jt` C;2 TYPE OF CASINGISTEE C DIA.OF WECASINO Zit p D PUBUC/MUNICIPAL ❑DRIVEN DEPTH Of GROUT SEAL I SPECIFICATION i A IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME D�� IJ F MONITORING GROUT SEAL PIMPED: Ely. ❑No CONCRETE PEDESTAL BY DRILLER:❑Yw [IN. S APPROX.DEPTHI J Fe�sj LOCKING CHESTER BOXISTOVE PIPE S PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER ✓ CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAGUtN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAGUIN 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-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION$AT(200144118-2423, COMPETE DRAWING A7 LOWER AREA PROVIDED, Slpned X G(?� � , Title 5 Dole pis' PLOT PLAN (Draw to al Scale)Sea to I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL BYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ]. DIMENSIONED OUTUNF.S AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY.... - Copy ........... . ..... ...... . ............. . .... ..... . . : . ..... . .:.....:. ............ . h Application AccepDEPARTMENT USE ONLY .-//—_ Dole I l� Ars$ ted By -- Grout Impaction By Data ;' Pump Inspeetien By Date Destruction Irupect)on Byy1 Date I Commm . te: ev -C^d^.I 3,I M.A-C-.ate ACCOUNTING ONLY: AID, FACR - PE CODES FEE INFO AMOUNT REMITTED CHECK,ICASH RECEIVED BY DATE _ PERMITISERVICE REQUEST NUMBER INVOICE DD$5 q 2