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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388,304 EAST WEBER AVENUE*STOCKTON, CA 95201388 (2091469-3420 NON-REFUNDABLE PERMIT EXPIRES I! YEAR FROM DATE ISSUED (Complete in Triplketel APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TIPS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE,C AFTER 9-1115.3 AND THE STANDARDS �OFF�SAN JOAQUIN COUNTY PUBLIC HEALTH SERMCCES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNi � 1IOS'Zrl�1.rG ?r'c-C\E?1_YIl'1 S7DuC-TVA) l/TTS. PARCEL SIZFJAPNN e0go y-&70 S-AMC44V�AAJ OWNER'S NAME ��11r )S /VI Gy hw'� Z!C- — ADDRESS 94, 'A l ,.!/ �c ,,PHONE ,�I�� '�(Jp CONTRACTOR�'lCn ADORES S�L/,C �//�/I -(27 �+--- #( 0 `" (,} " SUB CONTRACTOR n h ADDRESS �v�+r PHONE! V7 TYPE OF WELL/PUMP` ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONrToRiNG WELL S ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J ❑New❑Repeh H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) ❑ OUT -0F8ERVICE WELL ❑ GEOPHYSICAL WELL X SOIL BORING ❑DESTRUCTION' IN7EJVDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1( A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO A ❑ OOMESTICR'NVATE ❑GRAVEL PACKISIZE TYPE OF CASINOMTEEUPVC DIA.OF WELL CASING D © PUSUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑�1 OA710NIA0 ❑OTHER GROUT SEAL INSTALLED BY 1/�(��l �•� GROUT BRAND NAME !�c4'� �u E LY MONITORING I GROUT SEAL PUMPED: ❑Yes G<. CONCRETE PEDESTAL BY DRILLER:❑Yw 049 S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PPE �� S PROPOSED CONSTAUCTIONlDRILLENG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 6150 ftT •ej 1 Hf9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATION9 OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:9 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLONRNG: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT to ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOA04AN'S COMPENSATION LAWS OF CALIFORNIA.- THE7APPElCAN r MUST CALL 24 HOURS IN VANCE FOR ALL REOUIRED INSPECTIONS AT(2051 40*4423. COMPLETE DRAWING AT LOWER AREA PROVIDED. g// 91Sned X / � [ �. Title [ r Deft / /D.�/(O PLOT PLAN(01aw to So Ms)Scale "to 1. NAMES 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 DIrWCTION. EXPANSION OF SEWAGE DISPOM SYSTfMB, 3. 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, J DEPARTMENT USE ONLY APpllenlen Aeeeptetl By Oroul IMpeellen By _ _ Deta Pump Imp�tlan By _ One Destnrdlen Imp--Fon By Date Comments ACCOUNTING ONLY! AIDIr FACS O) PE CODES FEE INFO AMOUNT REMIT -- TED CHE FSH REctivEo SY DAT / PERMIT/SERVICE REQUEST NUMBER INVOICE l fL u 0 �� d Pub.Health Serv,-Enviro.173(3196)