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APPLICATION FOR WELLIPUMP PERMIT# SAN JOAQUIN COUNTY PUBLIC HEALTH SER S ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA%M1 4118 (209) 4883420 w. 1 _l.i� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CampMts In TyipRaats) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OB INSTALL THE WOW DESCRIBED.THIS APPLICATION 19 MADE IN COMPLIANCE WITH SAN JOAGUIN COUNTY DEVELOPMENT TITLE,CHAPTER 91115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. 27-1 JOB ADDRESSM AM 7 /L�./1�Zl �!] `��p r4)/y!`�Qy. CITY 'y ~v PARCEL SREI(0 �,�p� OWNER'S NAMErtGEArrEI-Aot SPR6C�!6L5 !s'IE4,tLQ 9LAa &RESSC Qc 60_(X i2 V 1MkNTF,LR 9S PHONEI W-I—g Z3 124 CONTRACTOR I YJ nl FC:4-�ER- ADDRESS "T-CI Y_.N.+T'O I'j 1 LICI r PHONE I��,3 L[l /�� SUBCONTRACTOR SPGcsJ-12KFVT ADDRESS J ��nT� UCIJIZJ-LGL 8' IONEt �_�J,7�1?, TYPE OF WEIVPVMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHEfl ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I_ i ❑Nea•❑RePelr H.P. DEPTH NMP SET—FT. FIRST WATER LEVEL O (TYPE OF MMPI ❑ OUT or 6ERVICE WELL ❑ GEOPHYSICAL WELL A IL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS / A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION t � 17 � 1N,DIA.OF CONDUCTOR CASINO _�(n' � O ❑ DOMESTICNRIVATE ❑GRAVEL PACK/SIZE TYPE,OF CASINOISTEFL/PVC NAhe DIA.OF WELL CASING ❑ PUBUCJMUNICIPAL ❑DRIVEN DE"NOFOROVTSEAL N4,41: !!l�P1NlJLN 1SPFCIFICATION ` t /�� R ❑ I GAibN/AG ❑OTHER _1/� GROUT SEAL INSTALLED BY S i LL��.Vu'w0R0UT BRAND NAME N/An E MONITORING�I L $0� 11 (r GROUT SEAL PUMPED: ❑Yee ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Ym LIN. S APPROX.DEPTH < _FCC== 1 LOCKING CHESFER BOX/STOVE PIIPPE/� S PROPOSED CONSTRUCTIONIdaLHNG METHOD: MUD ROTARY AIR NOTARY AUGER / CABLE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOIK WILL BE DONE IN ACCORDANCE WITH BAN"AMIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGINATION OF THE SAN JOAOUIN COUNTY. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CEITTIPV THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH TNIS R IS SSUEO,1 SHALL NOt EMROV PERSO SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONI RACTOR'S HIRING ON SUBCONTRACTING SIGNATURE CERTIFIES THE FOL WI '1 CER! NAT IN TIIE RRFO NCE,OF THE WOR(FOR WNICN TIIIS PERMP IB ISSUED,I SHALL EMROY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALLED IA.' PLl N M ST LL A 11 IN ADVANCE FOR ALL REQUITED INSIECTIONS AT 11/OSI�IY�-J,a/f]/COyMNETEE OM`LMNO AT LOWER AREA POVIVED. Blame% I S 1' 0.1. /1-19--9 11 ROT RAN IDrew le BPN.I BeNe 'm 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING TIIE PROPERTY. �. LOCATION OF"OUSE SEWAGE DISPOSAL SYSTEM On PROPOSED _. OViLINE OF iNE PRORRTY,GIVING DIMENSIONS ANO NOMN OINECTION. 910H OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSroNEO OUTLINED AND LOCATHIN OF ALL E%ISTING ANO PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,ANO WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. n1l ''• .,I�\y.(R\1/[� /A DEPARTMENT USE ONLY AP,11e0en Ae,"-!BY p 11LLES�{IJI�` &kL Groin Impeelbn By 1 \ Oete Mnp In.pmVen By T DHs De.IncHen Imnecllan SY D.le Cemmnm: ACCOUNTING ONLY: AID! FACS PE CODES FEE INFO AMOUNT REMITTED CHECKIICASH RECEIVED BY DATE IERMIT/SERVICE REQUEST NUMBER INVOICE AN 550 Pub.Health SEN.-Enviro.173(3/96)