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ILICATION FOR WELL/PUMP PERMIT ✓ SAN JvAOUIN COUNTY PUBVC HEALTH SERV,,�;S ENVIRONMENTAL HEALTH DIVISION J1 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 ' 1100-REFURDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compbts In Triplient$) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.TRIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AN THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. c —• V C� JOB ADDRESSOR APNI1�1=I I�, Ar'� CITU PARCEL 8t2E/APNI OWNER'S NAME ADDRE88 w PHONE CONTRACTORALA ADDRESS D UCM< 7.1"/_/—PHONE prV - -�4 ` ` ` "",i�� TooCC �� T P�vV BVB CONTRACTOR ADDRESS LI41�4 PHONE f TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL I ,c ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLI J ❑New❑Repair H.P. DEPTH PUMP SET FT- FIRST WATER LEVEL O (IYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHVBICAL WELL I ❑ SOIL BORING S ❑DESTRUCTION- INTENDED USF TYPE.FW EL CONSTRUCTION SPECIFICATIONS �� A ❑ INDUSTRIAL ❑OPEN BOTTOM e�� GIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINGIt VO ❑ DOMESTIC/PRIVATE GRAVEL PACK/SIZEI[I TYPE OF CASINO/STEEVPVCEv DIA.OF WELL CASINO ,J _ D ElPVBUC/MUNICIPAL DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R —be❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAM •q E ❑ MONITORING GROUT SEAL PUMPED: CKVe• []He-' Ne ��E PEDESTAL BV DRILLER:❑Vw 1@Ne S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE t I S PROPOSED CONSTRUCTIONIMLUNG METHOD: MUD ROTARY AIR ROTARY—)�—AUGER CABLE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN 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 WONK FOR WHICH THIS PERMIT 18 ISSUED,1 814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-4 COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUD-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOIK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' IRE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION$AT 12001400-3423. COMPLETE O WINO AT LOWER AREA PROVIDED. Signed X��// 1/�A Title ^ Dote PLOT PLAN IDraw to Scald Sad• 'to 1. NAMES OF STREETS 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. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. D MENDIONED OtTTUNF.8 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELL$WITHIN RADIVO OF ONE HUNDRED FIFTY FT. STRUCTURED,INCLUDING COVERED AREA$SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. E L _ t DEPARTMENT USE ONLY APPtbdbn Accepted By Dab O—A Inspeellen By Date Pump Inspection By Data Own-oan Impeetbn By Dale Cemmentr. r ✓ ,e O6•• —Loao� • • ACCOVNTINO ONLY: AID# FAC/ PE CODES FEE INFO AMOUNT REMITTED CHECX#1CA8H RECEIVED SY DATE PERMITIOERVICE REQUEST NUMBER INVOICE eM Alao�wv � Pub.Health Serv.-Enviro.173(1/97)