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V APPLICATIOR. w Op WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 466-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (CPmpleu In Triplicate) APPLICATION Is IIERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/On INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WHIZ SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CCH/AMR 9-11116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLICHEALTHSERVICES, ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESSOR AAM# �1 o' /�//v. �Ir /C/f//� r m CITY 7/72t /e Jp PARCEL SIZEIAPNI / p OWNER'S NAMEG%f - 0� ✓ ,/QGKC!T/TE S� ADDRES9 � PHONE I 'P7p 1�du�� GC�Fu��a�iiA1: sa�crrw may! _�7 G CONTRACTOR � Y ADDRESS / 2��/I/./�.J/��61.v/ � � 74/i41Ut/ ONE / BUS CONTRACTOR / .--r � ADDRESS 7"ON RHONE / TYPEOFWEUJPUMP: P( NEWWELL ❑ RE"CEMEM WELL uMONITORING WELL F � � � ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL / J ❑ NeuY ❑ Garratt H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL O RYPE OF PUMPI ❑ DVT-0f-SERVICE WELL ❑ GEOPHYSICAL WELLF ❑ BOIL BORING B ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS /1 A ❑ INDUSTRIAL ❑ O//PEN BOTTOM DIA, OF WELL EXCAVATION DIA. OF CONDUCTOR CASINO IV4 O 11DOMESTICNRIVATE );IiiMVEL PACKISIZE TYPE OF CASINOISTEEUPVC� DIA. OF WELL CASINO ❑ PURUCIMUNICIPAL ❑ DRIVEN DEPTH OF GROW SEAL �� ' SPECIFICATION � ss ws� R ❑ IRRIGATION/AG ❑ OTHER GROPER SEAL INSTALLED BV/LYNNI/'IJ �i Y/G��OROUT BRAND NAME I/y%rvf# + E AMONRORING GROUT SEAL PUMPED: ❑ Vs ❑ No CONCIIETE PEDESTAL BY DRILLER: ❑ Vee ❑No 5 APPROX. DEPTH LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTIONROSMING METHOD: MUD ROTARY AIR ROTARY AUGERX_ CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY- HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIER THE FOLLOWING: ' 1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORRMAN'S COMPENSATION LAWS OF CALIFORNIA.' mm TI CA LL 34 W B IN ADVANCE FOR AREQUIRED INnfPECTIONS ,,ATT (2091484-2423. COMPLETE DRAWING AT LOWER AREA PRO VIDED/. Planed IN X '�� ll Title / 06;NSI ?z/ note PLOT PUN (Or" to Soolel Scale ' to 1 . NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED E. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. - EXPANSION OF SEWAGE DISPOSAL SYSTEMS. { 3. DIMENBbNED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED a. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE P ETITI Y OR ADJOINING PROPERTY. DEPARTMENT USE ONLY ApplleMlon Accepted By Date p.0 Grein Impaction BY Dole Pump Inepecticn By ONs DatnmHlan Imnectla BY Date — ACCOUNTING ONLY: AID/ PAC/ FE CODES FEE INFO AMOUNT REMITTED CHECKOMABH RECEIVED By DATE PERMITISIAICE REQUEST NUMBER INVOICE Pub, Health Serv. - Envlro. 173 (3/96) f