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MEN _ .. y ` t ►LICATION FOR WELLIPUMP PERMIT, • 4 SANOUIN COUNTY PUBLIC HEALTH SER d S ' w �. ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Comphta In TTlpllcatal APPLICATION IF;FIFRE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-11 IS.3_M0 THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,EN RONMENTAL HEALTH DIVISION, JOB ADDRESSIOR APNf -%5-s- /�� CITY �� PARCEL SIZEIAPHO 7!5,17- OWNER,"NAME /�l�1J / �7 A�b0 8 3 SHOD[M�lc ��7 •�" CONTRACTOR f r'G! /1nnG£�/�- •/►��I ADDRE88 L1C# SVS CONTRACT ADDRESS r• f�+V �!`-!'!�'t+V I TYPE OF WELLIPUMR*, NEW WELL ❑ REPLACEMENT WELL MONITOMHO WELL f DlFIER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR © VAPOR EXTRACTION WELL IF J ❑New❑Rope, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O It YPE OF PUMPI ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL f Lb 8flR BORING R ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION 8PECIFICATION8 /Q / K A ❑ INDUSTRIAL 11 OPEN BOTTOM y� VIA.OF WELL EXCAVATION_rCy (�L `},�S /D DIA.OF CONDUCTOR CASING A- D ❑ DOMESTICIFNVATE LT GRAVEL PACKISIZETYPE OF CASINOISTEELG� IIIA.OF WELL CASINO '�jl D ❑ PVSLICIMUN1CiPAL ❑DRIVEN DEPTH OF GROUT SEAL_ S FaL-r%F'ECIFICATiON 1 r/-��9 R ❑.,, IIRRRIGATIONIAO ❑OTHER GROUT SEAL INSTALLED BY Df�� GROUT BRAND NAME.. -_ --_. f A� E w MONITORING GROUT SEAL PIMPED: ❑Yr 13 CONCRETE PEDESTAL BY DRILLER❑Yr [IN. S APPROX.DEPTH N�lll.a� LOCKING CHESTER BOxmmvii PIPE � PROPOSED CONSTRUCTIONRMULLINO METHOD: MUD ROTARY AIR ROTARY AUGER V CABLE OTHER 144MBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE GONE IN ACCORDANCE WITH BAN 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 WORK FOR WHICH THIS PERMIT IB ISSMO,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRNO OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA" T\\JJHffE/A//) CANT PAXOT CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED IINNSS/PWIRONS AT,12001 4aa-J422. COMPLETE DRAWINO AT LOWER AREA PROVIDED. Blaned X V�L,C�edfib Thte Dote ,•� '�� PLOT PLAN Mow to Sc+let Se.l. •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,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WFTHIN ItAbIUS OF ONE HUNDRED FIFTY FT, STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINWO PROPERTY. .. „.. .. - DEPARTMENT USE ONLY +f�`�S�A>�I7cwtlen AceePted'B>• r - - - -— r-_--rG.1�T A. _ Grout"peetton By Dole Pump Impeellen or Dole O"tnetien Fmp—Onn 11 O+te CommeMr. ACCOUNTING ONLY; AID# PACO PE CODES FEE INFO AMOUNT REMITTED CFIECKfICASH RECEIVED BY DATE PERMITISE RVICE REOUEST NUMBER INVOICE c�I I i Pub.Health Serv.-E:nvirD,173(1/97) I