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1PLICATION POR W9`LUPUMP PERMI' SAk-.,JAOUIN COUNTY PUBLIC HEALTH SEA7k,%ES ENVIRONMENTAL HEALTH DIVISION V 304 EAST WEBER AVENUE, STOCKTON, CA 95202 v (209)468-3420 U 1900-REFUODADLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompbta In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WrTN SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PU C HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ` I r JOB ADDRESS/OR APN# � ID� S- i(II � P � CITU PARCEL SIZE/APNM 9 OWNER'S NAME d� ADDRES6 _ ONE R C l /^ CONTRACTOR ADDRESS UC/PPNONE E SUB CONTRACTOR ADDRESS LIC PHONE TYPE OF WELLIPUMP: ❑ NEW WELL ❑ XPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Regal, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING )kDEBTRUCTION: Jjgj kvatS:Mjf1 INTENDED USIE TYPE OF WELL CON RUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTK:R'RIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D ❑ PUBLICRMUNICIPAI ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED:❑Yee [IN. CONCRETE PEDESTAL SY DRILLER:❑Yw [IN. S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONOTRUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER ----- I HE9EBY 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 REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CAUFORNIA.' T1/��PPUCANT MUQT CALL 24 HOUR$IN ADVANCE FOR ALL REOtARED INSPECTIONS A 12001 4CO-2423. COMPLETE DRAWING AT LOWER AREA M PROED. -Sa1Signed X 1 Title ^ Oate /LOT PLAN IDrtwv to Seelel Beala 'to 1. NAMES OF 8TREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENWONB AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYBTEMB. 3. DIMENCIONED OVTLINF.O AND LOCATION OF ALL EXISTING AND PROPOBED 9. LOCATION OF WELLO WITHIN RADRIB OF ONE HUNDRED FIFTY FT. STRUCTURES,IICLUMNO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. _..... l ;._.. .......... ..:. i ...:... .: ....:... .. .................:..................:......:......�......: \! DEPARTMENT USE ONLYz 7e, Q A I loatlen A tF J Q vM Accepted By rr•.. 1 _ �. D.G. p e rr----r•e-;'l l+;f-+� Mw Grout Inapeetlon By , !l 5,4Z -- - P�p Inypeotlen By Date Onew.tien ee In. tien P :_�,....-.'��..:.-__�..-. Data CemmerNr ACCOUNTING ONLY: AID# FAC# PE CODED FEE INFO AMOUNT REMITTED CHECK#!CASH RECEIVED By DATE PERMIT/SERVICE REQUEST NUMBER INVOICE Pub.Heafth Serv.-Enviro.173(1/97)