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APPLICATION FOR WELL►PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 3 P.O. BOX %304 EAST WEBER AVENUE. STOCKTON. CA 95201,388 (209) 488.3420 NONREFUNDABLE PER IT EXPIRES 1 YEAR FROM DATE ISSUED APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONST II UCTAND/on INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPM- ENT TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNI ` �- �Vic, O`K� L S'fl- LI O-34 •v OWNER'S NAME \,, �l �'rii~� i� PARCEL 812E/APNI --�•V�sS ADDRE86 �� t /_ ^tZ L� ��W_•N_�.�ty/.moCS I IS��t Ti tip .CONT-CONTRACTOR \ )Q u Am r BVB CONTPHONE —1� ADDRESS Cf-MU�PHONE MCTOR �1►�'t�l rU(y p�\ _ 1��rl -- ADDRE68_S_��S�- �G , CR J �¢ LZl PHONE aes=Llillk TYPE OF WELLIPUMP• y3 NEW WELL ❑ REPLACEMENT WELL MONITORING WELL I '1 j 3 ❑OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑New❑Repair H.P. ❑ VAPOR EXTRACTION WELL I � (TYPE OF PUMPI DEPTH PUMP SET FT. FIRST WATER LEVEL___ D ❑ OUT-OF-BERVICE WELL ❑ GEOPHYSICAL WELL I SOIL BORING �,,.,��r 1 8 ❑DESTRUCTION: INTENDED USE TYPE OF WELL _ CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_ u' ll A DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE DIA.OF CONDUCTOR CASINO D TYPE OF CASINO/BTEEUPVC_ �V[� DIA.OF WELL CASINO 4�1 ❑ PUBLIC/MUNICIPAL ❑DRIVEN y(ol y 4U D DEPTH OF GROUT SEAL_ Si'ECIFICATION ❑ IRRIGATION/AG POTHER R POTHER GROUT REAL INSTALLED BY rTj jk Le• GROUT BRAND NAME ❑ MONITORING F I MGROUT REAL PUMPED: ❑Vs [IN. CONCRETE PEDESTAL BY DRILLER:❑Yee APPROX.DEPTH 0 W-` Z 2p1 p� ❑Ne s �/ 1 1 LOCKING CHESTER BOX/STOVE PIPE PROPOSED CON$TRUCTIONIDgll-UNG METHOD: MUD ROTARYS AIR ROTARY AUGER_CABLE OTHER I HE9EBY CERTIFY THAT I IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFOnMANCE OF THE WOW FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN T{I PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- T PPUCANT VST A 2! URS I ADVA FOR ALL REQUIRED�I•NSPECTIO/N$AT(20$1 I$$JI23. COMPLETE DRAWING AT LOWER AREA PROVIDED. Started X Title C.�'I'�"l�t'i ./h .P /y�, rCi l o Jf" /��CfDotZ- �- �� y� 1 �/ T— PLOT PUN(Orsw to SoNel 3aNs _,._•to 1. NAMES OF ST FTS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. 4• LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEM@. STRUCTURE@,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. S. LOCATION OF WELLS WRT/IN RADIUS OF ONE HUNDRED FIFTY FT. ON THE PROPERTY OR ADJOINING PROPERTY. Ex��t«�T,elf �NvJ_4 G0�111ERU�l. Meth 044 W46-1 M lk'MMfL�(a�- MW-1 has S Ti�Tcowy, R�oeK DEPARTMENT USE ONLY APPliaetlen Aaoepterl ByJAJ a-,&" Date , 7- /q _Arse areal Impaction By Dote Pi P Impaction By Date Dm1rtwtlan Impsetlon By__. Dote Co—or,to: ACCOUNTINO ONLY: AIDI FACT PE CODES FEE INFO AMOUNT REMITTED CHECKIlCABII RECEIVED By /DATE PERMITI$EAVICE REQUEST Nl1NIBEq INVOICE e n Pub.Health Serv.-Enviro.173(3/96)