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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 5 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 WELLR ` • NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TrJLE,CHA R 9-11 .3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN+r CITY PARCEL SIZE/APN/ OWNER'S NAME `'` d ADDRESS PHONE R CONTRACTOR AbDRE C/�M1ONE SUB CONTRACTOR •Z7 ADDnEB UC6�PHON( .2,�977J _TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR VAPOR EXTRACTION WELL f ✓ ❑New❑Repair H.P. DEPTH PUMP SET FT. WATER LEVEL O (TYPE Of PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING a ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 3{n�� A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION / DIA.OF CONDUCTOR CASINO D ❑ DOMESTICR'RIVATE ❑GRAVEL PACK/81ZE_ TYPE OF CASINO/STEEL. ?If� / DIA.OF WELL CASINO D ❑ PUBLIC/MUNICIPAL ❑DRIVEN �n " DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIOATION/AQ ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING / GROUT SEAL PUMPED: ❑Vee No CONCRETE PEDESTAL BY DRILLER:❑Yea ❑No S APPROX.DEPTH LOCKING CHESTER BOX/ bVE� S PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AU`�ER_1�—CABLE OTHER 1 HE9EBV CERTIFY THAT 1 HAVE PREPARED THIS APPUCATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S 810NATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 814ALL 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 THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' T A ANT MUST CALL 2 IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1205)4641-342!, COMPLETE DRAWING AT LOWER AREA PROVIDE t r .�f/-•- Slaned X� ^'�!1 / Title �. hq j / Date PLOT PLAN IDrow to goals)Scale 'to 1. NAMED OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYBTEMS. 2, DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. _._ ...,. ..... ' ..>.. ? .. ..:.. .__i..... ....... .. .....i.. .. .. _. _. DEC.. :. (.... M1>PI .. :....... .. _. ...........i.. _..... .. ..... .. .. .. .. .... a r.visfIJM DEPARTMENT USE ONLY I Application Accepted By Dale Areae Grout IMPeptlon By vote��PUmP Inspection By Date baetnallon Inepectlon By Date Commerce: ACCOUNTING ONLY: AID# FACT 4122/JV/O PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE os � r S- Pub.Health Serv.-Enviro.173(1/97)