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)PLICATION FOR WELLIPUMP PERMr►,-./' SAN`�&OUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON, CA 95202 (209)468~3420 '5 ss NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplieatel APPLICATION IS"ERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPUA E WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION.JOB ADDRESS/OR APNI 4/ !q /V _ A�f �/ t CITY �; PARCEL 81ZE/APNI / •/ _��/ v -Pb /J `/ /7 J OWNER'S NAME_- / eiA r�7�''-�' 3,t- ADDRESS- //�� •1�/rL.Bp 7�� '^ T72 �L.�PHONE f ( �'S ��/ CONTRACTOR-.442 "A �`� ADORES.41a7 �Ake 1�"T�L(Y/�1 , NE/�VtO BUB CONTRACTOR ADORES lr&440L +� :;;e— UCO PHONE/ TYPE OF WELLMUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLR ❑OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ./ {TYPE OF PUMP) ❑New 13Repeh H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL Ir11.BORING a ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEUPVC DIA.OF WELL CASINO p ❑ PUBUCAMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION q pIR ❑ IRRIGATION/AO 1:1 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAM E LY MONITORING GROUT SEAL PUMPED:❑Yee CONCRETE PEDESTAL SY DRILLER:❑Yee [IN. S APPROX.DEPTH LOCKING CHESTER BOXAGTOVE PIPE l / S PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OAIER I HE-WRY CERTIFY THAT 1 HAVE PREPARED TWO APPLICATION AND THAT THE WOW 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'8 SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTI%ACTnNO SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I$HALL EMPLOY PERSONS SUBJECT TO WORKMAN'.COMPENSATION LAWS OF CALIFORNIA.' THE CANT MUST�URS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091400-2422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Blpned X F/iA'�!)� R� Title ( ` Dete PLOT PLAN Skew to Bowel Serle 'to 1. NAMES OF STREET$OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSION.AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTUWF..AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELL.WITHIN RADIOS OF ONE HUNDRED FIFTY FT. STRUCTURES.INCLUDINO COVERED AREA.SUCH A.PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. DEPARTMENT USE ONLY Aeelleatlen Aeeepted BYazc'�� Date Z Z i�7 F, Mee Grout inapeetlen BY Dete Pimp inspection BY Date Deatn'etlen lnepeetlenBYL�e /j, Dela CemmtwNe• /�/ I `��/ 255 ACCOUNTING ONLY: AID# FRCP PE CODES FEE INFO AMOUNT REMITTED CHECXI/CASH REC er DATY PERMIT/SERVICE REGUEST NUMBER INVOICE S 0 Pub.Hea@h Serv.-Enviro.173(1/97)