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`PLICATION FOR WELUpUMP PERM17 a SAN\v4AQUIN COUNTY PUBLIC HEALTH SER%.:dES ENVIRONMENTAL HEALTH DIVISION (� 304 EAST WEBER AVENUE, STOCKTON, CA 952 I t (209) 468-3420 f nON•REFUNABLE PERMIT EXPIRES 1 YEAR FROU DATE ISSUED ��MApWrIHSAN(Complete in Trk&ntel APPLICATION 18 HERE SY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN CO P JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE 7ANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNI SDO CITY r�+ PARCEL SIZE/APNI r 7r1 „r U I-7 OWNER'S NAME W ADDRESS ` f� s r #-"I - •�f--�y�/- _ E-.qPHONE I ADDRESSt,1;( c C12 P�7 [ a I' �; j O CONTRACTOR LK:/ PHONE RVB CONTRACTOR ADDRESS [`Le ` UC# PHONE Ig/G _TYPE OF WELL/PUMP: ❑ NEW WELL 1:1 REPLACEMENT WELL pT MONITORING WELL I�,1 t7 ❑ OTHER �./ ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROBS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I RYPE OF PVMPI ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELLI ❑ BOIL BORING g ❑DESTRUCTION: 1-1 INDUSTRIAL ❑OPEN BOSPECIFICATIONS OM DIA.OF WELL EXCAVATION ' DIA.OF CONDUCTOR CASING p ❑ DOMESTIC/PRIVATE I�GRAVEL PACK/612E TYPE OF CASING/STEEL/PVCT �� DIA.OF WELL CASINO "I ` O ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY t-I GROUT BRAND NAME E I�MONITORING Q\ GROUT SEAL PUMPED: 50 Yee ❑Ne �NCIIEI:E PEDESTAL BY DRILLER:❑Yee We S APPROX.DEPTH �e LOCKING CHESTER BOX/STOVE PIPE v S PROPOSED CONMTRUCTION/DAILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I"MBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT Ig ISSUED,1 SI4ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SVB-CONTRACTINO 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-e COMPENSATION LAWS OF CALIFORNIA.' nPPUCANT M�U8ZC//ALL 2,4 HOURS IN ADVANCE FOR ALL REGUMID INSPECTIONO AT 12001 4COdM422. COMPLETE DRAWING AT LOWER AREA PROED. Blaned X / TIUa'AA Y � Data PLOT PLAN(Drew to Bowel goals 'to vT�" 1. NAMES OF OTREETO OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2, OUTLINE OF THE PROPERTY,GIVING DIMENSIONM AND HORrH DIRECTION. EXPANSION OF SEWAGE DISPOOAL SYSTEMS. 3. DMRENSK)NED OUTLNF.O AND LOCATION OF ALL EXISTING AND PROPOSED 0. LOCATION OF WELLS WITHIN RADIUM OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAE SUCH All PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PNOPEf" r . ..:`. .. ... .....:. � DEPARTMENT USE ONLY .: ....:..... ........... ....: .•..... Appllestlen Accepted By Date Ares Grout Impeetlen By Date Pump Inepeotlen By Data Destruction Inepectlon By /-1 Date O ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SFAVICE REQUEST NUMBER INVOICE „� ✓. oOn, 0/0 Pub.Health Serv.-Enviro.173(1/97)