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'PLICATION FOR WELLIPUMP PERMIT SA"OUIN COUNTY PUBLIC HEALTH SEF dkS ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 ZION-REFUNDARE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICemplala In TTipRcatal APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIN APPLICATION IS MADE IN COMPLIANCE WTI!SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER B-111 AN THE STANDAR��.Y VIN COUNTY PUBUC,fHEALTH SERVICES,ENVIRONMENTAL HEALTH OIVISION. JOB AODRESS/OR APNr I��It'L �� _._ G A R PARCEL StZEIAPN# OWNER'S NAME ADDRESS •[ 11' C PHONE CONTRACT014 ADORESS._ T'D=' _ _._UCM6?R 4Il�`PH0�F!E r � �y7'� SUBCONTRACTOR ACTOR �] ADDRESS ^ - Y12:9 4'�/iL7 PHOl�► -SOV G�.C,7 2 TYPE OF WELL/PUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL r ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ Ct1088CON4ECT REPAIR ❑ VAPOR EXTRACTION WELL r J ❑Nen❑Rnpelr N.P. DEPTH PUMP SET FT. FIRSLWf/�T LEVEL O (TYPE OF PUMP) ❑ OUT-OFSERVICE WELL ❑ GEOPHYSICAL WELT.r ISDIL BONNG S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 7�r DIA.OF CONDUCTOR CASING O © DOMESTICIPIBVATE ❑GRAVEL PACKIRIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO O ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R IJ IRRIOATIOWAG ❑OTHER [GROUT SEAL INSTALLED BY � GROUT BRAND NAME E L}!MONITORING /��a GROUT SEAL PUMPED: ❑Y. Ne CONCRETE PEDESTAL RY ONLLER:❑Y« ❑Na S EP APPROX.DTH [.L G' LOCKING cwimn SOXISTOVE PIPE S PROPOSED CONSTRUCTION/DRILLING MEt110b: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APL CATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCE$,STATE LAWS,AND RULES AND RFOUI.ATIONS OF THE SAN JOAOVIJ COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWMG:'1 CERTIFY THAT IN THE PERFORMANCE OF TIIE WORK FOR WIBCH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'*HIRING OR SUR-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,t SHALL EMPLOY PERSONS BUBJECT TO WORKMAN'S COMPETPSATPON LAWS OF CALIFORRHAA..'�lr CANT M1UST CALL UIS IN ADVANCE FOR ALL REQUIRED IN a AT 1'2061 4aa9422. COMPLETE THIAWING AT LOWER AREA PROVIDED. S* d X W 1 TIPe Otte PLOT PLAN(Drew to Seale)SeNe to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAOE DISPOSAL BYSTEM6. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXITING AND PROPOSED S. LOCATION OF WELLS W?ITIIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIO*,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. .... ;... DEPARTMENT USE ONLY Appaeellen Aseeped P, DO ' Ay Grout I.rpecllen BY Date Renp Irnpeetlan By DNe Omtnreltan lmpeelan BY bele Cemments- ACCOUNTING oNtV- AIDr FACT FE CODES* FEE INFO AMOUNT REMITTED CNECKFfCASH RECOVED SY DATE PUMNBTISUMCE REOVEST NUM&ER INVOICE O Pub.ileaRh Serv.-Enviro,173(1/97)