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APPLICATION FOR WELL)PUMP PERMIT 1` SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON. CA 95201388 (209) 466.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplienis) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY Fort A PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCnIRED.Title APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION• JOB ADDRESS/OR APNN. { �lt+' ��/ ;/( � cirr_ �G Z�J - PARCEL SIZE/APNI OWNER'S NAME �✓/� �p(� /J�-fir^�� /�6Q-= -- f ZONE I�Q�7 CONTRACTOR 14C4&- I(K ��/) NI/�i/� � ADDRESS��1 O,//I I/� LIC/ Z� MIONE I .7{v OUR CONTRACTOR ADORFSC�(C4/ �' Sf- l d LICI `��1 Pt10NE I TYPE OF WELL/PUMP: ❑ NEW WELL ❑ nFPLACF.MENT WELL ❑ MONITORING WELL IV �Ef.fn 5; P D• ❑ INSTALLATION ❑ WELL SYSTEM FIEPAIn ❑ CnOSS-CONNECT REPAIR L7 VAPon EXTRACTION WE / it ❑ (TYPE OF PUMP) New❑Rrgelr H.P. DEPTII PUMP SET FT. FIRST WATER LEVEL d O ❑ OUT-OF.SEnVICE WELL ❑ OEOPI IYSICAL WELL R ElSOIL ROMNO N ❑DESTRUCTION: INTENDED USE TYPE OF WELL 60NSTSVCIION 8PECIFICATI0N8 !I A ❑ INDUSTRIAL �❑OPEN BOTTOM (�J DIA.OF WELL EXCAVATIO--El/r{'� �•�r�s�� DIA.Or CONOUCton CASINO /V/'/ n ❑ DOMESTICMMVATE 1_]GRAVEL PACK/SIZE D' 19-"" TYPE OF CASING/A�Jf rC -yry C. S/r�i� DIA,OF WELL CASINO r r ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPT11 OF GROUT SEAL_ /✓ S'Ly1G}' C _ SPECIFICATION ❑yIRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY__!,:? Ie�j OnOI/T BRAND NAME �i E G MONITORING GROUT SEAL PUMPED: ❑Yrr� No 1--�� 15-320 ( � CONCRETE PEDESTAL BY bRILLER:❑Vr W. 5 APPno X.DEPTH LOCKING CHFSTEn pZU/TOVE PIPE / 5 PROPOSED CONSTRUCTION/ORIWNO METHOD: MUD ROTARY AIR ROTARY AUGER ✓ CABLE OTHEf(VG�LI`i/Y� I HEREBY 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 TILE BAN JOAQUIN COUNTY, HOME OWNER On LICENSED AnENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOn WIIICH THIS PERMIT 18 ISSUED,I SIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-19 COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUR-CONTRACTING SIGNATURE CERTIFIER THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONA SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CW 24 HOURS IN ADVANCE FOR ALL REOUIRED�INSPECTIONS AT 12001409-3423. COMPLETE DRAWING AT LOWER AREA P"OVIDEO. ok-8lorwd X_.`�✓ ✓"'TAta./ Till D.I. PLOT PLAN QD to Rnwlwl Aowlw •to 1, NAMES OF STREETS OR ROADS NEAREST TO On ROUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORT/t DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 7. DIMENSK)NED OLTTUNFS AND LOCATION OF ALL EX1971NO AND PROPOSED 8, LOCATION OF WELLS WITHIN MDIVB OF ONE HUNDRED FIFTY FI. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY On ADJOINING PROPERTY, PAYMENT ...... RECEIVED . i i .. ..... .. .. }•, Pr. �..1 fil Ji)r __. ._ SA. I .- �,yn y,7 DEPARTMENT USE ONLY APPIIoMIon Aeewpled By a'�W�^. DMw_ /,JJ - /�� Arew �'�1 U �-1 •U I O—A I_Pootlon By .I' Owtw Awnp In�nwollon Sy / De1w D000mtlon Irnpeellen By DNw CemmerNr ACCOUNTING ONLY: Alod FACT PE CODES FEE INTO AMOUNT REMITTED CHEQK AAH I RECEIVED By DATE PERMIT/SERVICE BEQUEST NUMBER INVOICE .0 Pub.Health Serv.-Enviro.173(3/96)