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MPLICATION FOR WELLIPUMP PERMIT SAN OUIN COUNTY PUBLIC HEALTH SERV S ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON, CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED (Complete iB TtipReetel APPLICATION 19 HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK MnMBEO.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAOUIN COUNTY DEVELOPMENT TITLE, HARED 8-11 6.3 AND T41E BTANDAROS OF SAN JOA COUNTY PU IC NEA H BBIVICES.ENVIRONMENTAL HEALTH DIVISION. Jog ADDRE9aroRCAP,N,f Ita f tI cI ..LL��>PAMMEL SIZEIAPNe•��j OWNER'S NAME D• =1/�' _A'�enLl�h ` � P"� ADDRESS 1 V ." _ PHONE ICYI CONTRACTOR f /m//�� \O11__ ADDRESS//��E'TE''�Y IN PHONE qq�A SUB CONTRACTOIN6x ADDRESS ISE F PHONE F 0 I V U TYPE OF WELUPUMP• ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL F Ip OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROS"ONNECT REPAIR {L-J VAPOR E%TRAC ON WELL/ •I ❑Nwv❑Rm.lr H.P. DEPTH PUMP SET__FT. FIRST WATER LEVEL 0 TYPE OF PUMPI El WE ❑ B OW-OFSERVICE WELL ❑ GEOPHYSICAL WELL J SOIL HOPING ❑DESTRUCTION. INTENDED USE TYPE OF WELL CONSTRUCTION EPECIFICATIONE A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO 0 ❑ DOMESTICB'mVATE ❑ORAVEL PACKISIZE TYPE OF CASINGISTEELIPVC VIA.OF WELL CASING r/0 ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF SPOUT SEAL 1 SPECIFICATION QIfO IA ' ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY• GROUT BRAND NAME JJ E ❑ MONTORIM GROUT SEAL PUMPEO: Ym ❑N. CONCRETE PEDESTAL BY DRILLER:Ely- ❑N. a APPROX.CERN LOCKING CHESTER SOXMOVE PIPE S PROPOSES CONERGRaT10NRNELUM METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER6yJ"�e-- 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAUUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CET IFY THAT IN THE PERFORMANCE OF THE WOW FOR WINCH THIS PERMIT IS ISSUED,I04ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'e COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR 811"OWRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1ORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WOREMAN'S COMMSAT1ON LAWS OF CALIFORNIA." THOMS IN ADVANCE FORAM ASOUNSM INSPECTIONe AT C10E1I0eJ. S. OMIA'LLEEFEE DRRA1 WING AT LOWER AREA PROMO ahs% . TlRla �1•'LL/�� D.I. �5 en aw 0AW66n tlz' ' E YDr.ry le BOYaI Aetl. I ' le 1. NAME F STREEROPETTY. E. LOCATION OF HOUSE SEWAGE M-SYSTEMS.SYSTEM OR PROPOSED Z. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION F SEWAGE THIN RAI BS OF ON S. ROTATION OF WELLS ADJOINING RADIUS OF ONE HUMORED FIFTY R. ].STRUCTURES. OUTLINES AND LOCATION OF ALL EXIAS pATO AND PROPOSED ON THE PRORRIY OR ADJOINING PPAPLRT'. STflVCTVREe,INCLVDINO COVERED AREAS SUCH AS PATIOA,ORIVEWAYB,AND WALKS. pp�� - y _ J � 1 Y�LF G � v - t Ts �- It X x•— QrL;�c'Szf'� �a�'C�12't)�- •X DEPARTMENT USE ONLY APPN..R1.n AmmRM By �„� OreU Impmtlen By �T( O.Ra PmP In.PmNen By V.Ra D.R. DM1ncRbn ImP/mr'lon By �^ / _/�(E� ea'l P+V� � ( PILO ACCOUNTING ONLY: AIDF 'V PE CODES FEE INFO AMOUNT REMITTED CHE /CASH RECEIVED BY DATE POWITARM"CE REQUEST NUNUIER I INVOICE Pub.Health Serv.-Enviro.173(1/97)