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'Ifto APPLICATION FOR WELLIPUMP PERMIT a SAN JOAOUIN COUNTY PUBLIC HEALTH SERVIChm"' ENVIRONMENTAL HEALTH DIVISION Roo BOX 38% 304 EAST WEBER AVENUE, STOCKTON. CA VMi- 8B 12091468-3420 NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Memplets I APPLICATION IS HERE BY MADE TO THE SAN JOAOUCOUNTY FOR A PERMIT TO CONSTRUCT in I N AND/OR THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 ANDLTiHE STANDARDS OF SAN JOAQUIN COUNTY Y PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DVION. JOB AOpRE9SA7R APNI 1 Z `/ / _CITI / IOrGdl; /J PARCEL SIZE/APN�► OWNER'S NAME it Q V C GIS I'/) � t l rI 1 e- ADDRESS 1�/T'Is-Q PHONE Q z p CONTRACTOR I' EP2 ��'I rG�c�►-!N ADDRESS �7 /' IJCF PHONE•��+�' ✓a PUB CONTRACTOR �-�L I^(,(lyl/l I.!"'xYJL!]Ir_ ADDRESS r� LIJ L[J11 wQwwl LICE PHONE N TYPE OF WELL/PUMP; X-EW WELL ❑ REQFPPLAACE10AE=NT WELL ❑ MONITORINO WELL• ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROS9-CONNECt REPAIR ❑ VAPOR EXTRACTION WELL p J ❑ (TYPE OF PUMpi New 11Rapalt H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT-OF.SERVRCE WELL ❑ GEOPHYSICAL WFLL V 11 colt.BORING s 1:1 DEBTRISCTION; INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A [3INDUSTRIAL E3OPENOPEN BOTTOM DIA.OF WELL EXCAI ��( .} DIA.OF CONOVCTOR CASING � D ❑y DOMESTIC rmvATE RSI OMVEL PACKIRIZE 4 TYPE Of CASINOISTEEL PvC 5 GPVC'1Q r V C OIA.OF WELL CASINO1�_,,,, O ❑ PUBLICIMUMCIPAL ❑OMVEN OEPFH OF GROUT SEAL - —J N _ SPECIFICAT10h R ❑ IIL►YGAtIONIAO ©OTHER GROUT SEAL INSTALLED BY r GROUT BRAND NAME am E AMONITORPNGr OROUT SEAL PIMPED:A ea No CONCRETE PEDESTAL BY DRILLER;[? wm ❑Ne S APPROX.DEPTH LOCKING CHERTER BOX/VOVE PIPE 5 PROPOSED CONSTRUCTIONIbRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER 1 HEAEBV CERTIFY THAT 1 HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL ISE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THISUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIfOnMA.' CONTRACTOR'@ HIRING OR RUB-CONTRACTINO SIGNATURE CERTIFIES THE OtAOWINO: 1 CERTIFY THAT IN THE PERFO ANC THE WORK TOR WHICH THIS PERMIT 19 I8SUEb,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF C ORHIA- T 4PPSCANT MUST C 24 I NCE FOR ALL RtCKMFD IMZPWTION8 AT 12MI 4853422. COMPLETE DRAWING AT LOWER AREA PROVIDED. B�� TBI. 3-z'I - _ Dat. PLOT FLAN Ibraw to Beelef Coal. "to 1, NAMES OF STREETS OR ROADS N TO OR BOUNDING THE PROPERTY. 4, LOCATION OF PIOUS£SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUNE OF THE PROPERTY,011 fMFNSIONR AND NORTH DIRECTION. EXPANSION Of:BEWAOE DR@POSAL SYSTEM@, 2, DIMENSIONED OUTLWF.8 AND LOCATION OF ALL EXISTING AND FR OPOeEO S. LOCATION OF WELL@ WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. 1 DEPARTMENT USE ONLY AppBeatlen Accepted By 1A4 6 bole Mw Grout kopeelbn By Date Pump kvpeetlen By Dale D"Ittictien krpaeilm S oat. Comremrta: ACCOUNt1NO ONLY: AID/ FAC& PE CODER FEE INFO AMOUNT REATTM CHECK/ICA H RECEIVED BY DATE FEIYBTISERVICE REQUEST NUMBER INVOICE 0 Pub.Health Serv.-Enviro.173(3196)