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OPLICATION FOR WELL/PUMP PERMIT• SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (ComplatE IB TrIpRelRIl APPLICATION IS HEM BY MADE TO THE SAN JOAGOW COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOR(DESCIII TIRE APPLICATION 18 MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE, NAPIER 9-i l 6.7 AND THE 6TANDAPOB OF BAN JOAOAO PV SIC NEA H SERVICES.ENVIRONMENTAL HEALTH DIVISION. �I d `A� yJOB ADDRESSIOR APNI Y',1. //l Y' IJ�� /� /1,M � 1+' 1J J�,, vArxEl BrzEJAPNI OWNER'S NAME- �{1 ` 1 /r I/� ADDRESSU Q /� t v,\ PHONE(/^ WADDRE �`UCT-. r' RgNE RugCONYFACTOT /` U�LPLL htl'`hGT ADOR '7 I �g1pNEs I �7 —7 TYPE OF M1UJPUMP ❑ HEW WELL ❑ REPLACEMENT WELL ❑ MONRORIND WELL, IJIL OTHEq 1 D ❑ WSTALLATMN ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR {L_J:VAPOR E%TRAC ON YJELL/ J ❑N. 0 R.PNr H.P. DEPTH PUMP SET—FT. FIRST WATER REVEL O RYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL! ❑ SOR acrem B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING V ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGMTEEUYVC DIA.OF WELL CAA�S.I.N�LO.�,� � D ❑ PUBLICIMUNICIPAL ❑DmVEN DEPTH OF GROUT SEAL �I � t'p SPECIFICATION C2, " L - 1 r``(M ❑ IRmOATMN/AD ❑OTHER GROUT REAL INSTALLED B g GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: Y.. ❑N. CONCRETE PEDESTAL BY DRUER'❑Y- ❑N. S APPROX.DEPTH LOCKING CHESTER SOXISTOVE RPE S PROPOSED CONSTRUCTIOMmPlUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER RL I HEMBY CERTIFY THAT I IIAW PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAGUIN COUNTY ORDINANCES.STATE LAWS.AND RULES ANO REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR MERGED AGENT'8 SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I MALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'/COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S"MING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN RIE PEPFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORMA.' TCAPET IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT UtOIR AprtlJ(`A{3/f.I/90M/PL�ET/E/D�MVANO AT LOWER AREA PIK . BIpr.M% 1 1 . Till.J/t}IltC 1 COJ iu- ;1; 1 H�ME6OF STREETS On ROADS NEAREST tR BOUNDING TH[PROPERTY�r•l 8e.1. 1 to 51 J t LOCATION OF MUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED Z. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. G. DIMENSIONED OUTLINES ANO LOCATION OF ALL EXISTING AND PROPOSED S. LOCATMN OF WELLS WITHIN RAmUS OF ONE HUNDRED FIFTY fT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAMS. ON THE PROPERTY OR ADJOINING PROPERTY 50 f� t i - DEPARTMENT USE ONLY APe11..Ilen Aveeeled RY T/�I\ ,,A,1..,�1n D.t. // l/ ��M.. ��•, b TT Or.m impeetbn BY \ Da. Pun.In.esOen BY D.M D�1nFllen ImP..tbn BY �Q.. / L ON. n � Z. L."�o-�� JL? S.� � . Y.. /`f.[.L tclklf 1 ACCOUNTING ONLY: NOI FAC) PE CODES FEETWO AMOUNT ADMITTED CHE /CASH I RECEIVED NY DATE P[MRTISERVICE REQUEST NUMI'm INVOICE Pub.Health Sam-Enviro.173(1/97)