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r rV. j APPLICATION FOR WELLiPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERYIL'�g ENVIRONMENTAL HEALTH DIVISION y � P.O. BOX%% 304 EAST WMEA-AVENUt,`STOCKTpN, CA 8,ri2Q1v8 (209) 469.3420 M011•REFUNOABLE PERMIT El(pIRE3 � YEAR FROM DATE ISSUED {CNSTRU R!R DI lkalE) APPLICATION f8 HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANp�OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE 1N COMPLIANCE WfTR1 SAM JOAQUIN COUNTY DEVELOPMENT TITLE,CHA ER fl-1 i f 6.3 a D THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC RIEALDE SERVICES,ENVIRONMENTALIAPICATIOHEALTH DIVISION. JOB ADORESS/OR APN/ �� I t V y nn ` Corf R4 PARCEL SIZEIAPN# ' OWNER'S NAME�a h+t� t W,,,J_C � � o k ADORESB comRAcroR F ] �' �� ' PHONE r L o 1 5 3 t C \r ' lA , ADOR£SS I G BUB CONTRACTOR ,^ t33 "'C/ Irj�c� z7 PHONE/'ZEy(j 1510-Z4 ar% n AODRE8B�31 � +, LIC/-Vpi A-0-7-2-1 PHONE TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REMACEMENT WELL ❑ MONITORING WELL R ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ OTHER ❑ CR098SONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ ❑New❑Repair H.P. DEPTH PUMP SET ITYPf OF PUMPi -FT. IR WATER LEVELr a ❑ OUT-OF-sERvtcF WELL ❑ GEOPHYSICAL WELL/ 01 SOIL SORINO 3 Geo rn El B DESTRUCTION: t INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS_ ❑ INbU&TRIAL ❑OPEN BOTTOM �l /V A DIA.OF WELL EXCAVATION I DIA.OF CONDUCTOR CASINO D ❑ D BUST CRRIVATE 11 WOORIVE" PACK1812E TVP£OF CASINOISTEFLjPVC_N Jay DIA.OF WELL CASINO 1�_ ❑ PUBLICTIUNICIPAL Ii1LORIVEN DEPTH OF GROUT SEAL p SPECIFICATION "lij D i R ❑ IRRIGATMWAO ❑OTHER GROUT SEAL INSTALLED BY AfInj'C A!,0z, OFiOUT BRAND NAME F y MONITORING d GROUT SEAL PUMPED: ❑Ys �Ne CONCRETE PEDESTAL BY DRILLER:®Yr ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE�� -y}1 S + PROPOSED CONSTRUCTIONMRELUNO METHOD: MUD ROTARY AIR ROTARY A"ER CABLE OTHER Gk- 7 Q, I H£4ERY 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 JOAO"COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISBUEO,1 SHALL NOT EMPLOY PERBONB SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,' CONTRACTOR'S HIRING OR SUB-CONTRACTINO SIGNATURE CERTIFIER THE FOLLOWING; 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THI9 PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT To WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THS APPUCANT MUST CALL 24 HOURS 1 ADVANCE FOR ALL REQUIRED RISIMCTTIONS AT 12"1 4604422, COMPLETE DRAWING AT LOWER AREA PROVIDED. Owned X �!/J , TSIs Rim'I d j10�/�` ....�_ D.te 12 2 MOT PLAN Ibraw to Seaiel Seale 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 9. DIMENSIONED OUTLINFS AND LOCATION OF ALL EX19TINO AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Ff. , STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. .. .. :... .... Tf 9.1 ... 14 _.. _ :. ...: ... ................ .. ..: T .:.. ......... .. � r, DEPARTMENT USE ONLY ff Applkat%n Accepted BY Dae �^'' 1 � Yr _Mee 4. Grout h-peetMn 9Y Dole PL—p IMpmtlon BY Date Deetna:tlen Impectlen BY Dae I iLen+menu• ACCOUNTING ONtY; AID# FAC# PE CODE$ FEE INFO AMOUNT REMITTED CHECK#7CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE DI I c 25 f _ Pub.Health Serv.-Enviro.173(3196) I