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APPLICATION FOR WELLIPUMP PERMIT N JOAQUIN COUNTY PUBLIC HEALTH SERVICES �. ENVIRONMENTAL HEALTH DIVISION r P,O. BOX 3M 304 EAST WEBER AVENUE, STOCKTON, CA 95201358 (209) 469.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompfttt In TTiplksttl APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 16 MADE IN COMPLIANCE MRH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11155.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. I`4D W- qr�T JOA ADORESSroR APN/I j tV'� CIT'/ � C� � V-\ � r PARCEL SIZE/APN/ OWNER'S NAME ki'j CDC& ADDRESS L1�C _.C ') ) PHONE I S�-5/�-q-9'7�S�0 CONTRACTOR ADDRESSPHONE0 AVBCONTRACTOR ' �C/ ADOnFSBI/'7 i-/ U '� -7 C(/' LIC 7-% r �pNpljE rr -(p3 c�S rYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL nNyg-lyEtT'T ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECTREPAIR ❑ VAPOR EXTRACTION WELL f ❑New❑Rep N. H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O TYPE Of PUMP) ❑ OUT-Or-SERVICF WELL 11 `rye,GEOPHYSICAL WELL/ JLC SOIL BOn1NG Dr3 3 I D33 S ❑DESTRUCTION! / ` INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS (l A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O ❑ OOMF9TIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC :wry DIA.OF WELL CASINO D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL r7'` SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY !/)/w `_ GROUT BRAND NAME p ❑ MONITORING GROUT SEAL PUMPED: WY- ❑Ne CONCRETE PEDESTAL BY DRILLER❑Yw ❑No S APPROX_DEPTH LOCKING CHESTER BOXJf'i:P _ E f1:-E_ _- �_ / S PROPOSED CONSTRUCTIONMRILUNQ METHOD: MUD ROTARY ___AIR ROTARY AUOEn CABLE OTHER re1�T I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND IIEGUTATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF TIIE WOW FOR WHICH THIS PERMIT IB 188 V .I TALL NOT EMPLOY PERSONS SUBJECT TO W RKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING; 1 CETTIIIFY THAT IN TIE QFIMANCE C]F THE RK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." T E APPLICANT MUST CALL ♦I�DURt FOR ALL REQUIRED INS►E+C TIONt AT(2001 40111,3423. COMPLETE DRAWING AT(OWER AREA/PRO ED. SIC—d X ✓ (� C Title �Lj -J O � O.t. �� I i PLOT PLAN(0,—to S-1.1 SoeN 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. ♦. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PIOPOBED 2. OUTLINE OF THE P10PfRTY,GIVING DIMENSIONS AND NORTH DIRECTION- EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. DIMENSIONED OUTUNFB AND LOCATION Of ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WTTI/IN RADIUS OF ONE HUNDIIFD FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. DEPMTMENT USE ONLY Appllc.tbn Aceonled 9v—/T' G.cu impeeelen By Dae Penp Impentlnn By Oeet.mtlon Imvoctlon BY Dpt• Dap V ACCOUNTING ONLY: AID/ t FACS J+ PE CODES FEE INFO AMOUNT REMITTED CiIE�MASN RECEIVED BY DATE ��OI OQ PERMIT/tERVICE REQUEST NLIMSER INVOICE 113 6'l �► Z Pub.Health Serv.-Enviro. 173(3/96)