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APPLICATION FOR WEL.UPUMP IMIT jAN JOAQUIN COUNTY PUBLIC HEALI n SERVICES L" ENVIRONMENTAL HEALTH DIVISION r/cam p 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 110111-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED IComplttt IB Mplktlt) APPIICAFION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/Oft INSTALL THE WOW(DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SA JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11 15.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN/ `� 7? I CITU L-Ci(� `) _ / PARCEL SIZE/APNI OWNER'S NAME. / ,C (�/L-.� ��7 T' 'n 1•t �r I ADDRESS PHONE I CONTRACTOR F'� I��E \1)/ V ADDRESS ( LIC. 'ly/Op E SUB CONTRACTOR ADDRESS UC/ PHONE TYPE OF WELL/PUMP; ❑ NEW WELL ❑ REPLACEMENT WEIL •�❑�/MONFTORINO WELL If ❑ OTHER_ ❑ INSTALLATION ❑ WELL SYSTEM REPAIR I,J(CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL ❑N.w❑Repoli H.P. DEPTH PUMP SET FT. iiYPE OF PLIMPIFIftBT WATER LEVEL ❑ OUT OF-SERVICE WEIL ❑ OEOPHYSICAL WEIL I ❑ SOIL PORING 6 ❑DE 6T R11CT ION: INTENDED USE TYPE Of WELL CONSTRUC ION SPECIFICATIONS A ❑ INOUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING ❑ DOMEBIICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CAGING/GTEF(1PVC DIA.OF WELL CASING 1 ❑ PUBIIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yes ❑No CONCRETE PEDESTAL BY DRILLER:❑Y.. [IN. S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRIICTIONIDRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER_ CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED 7III8 APPLICATION AND THAT THE WOW(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AN REGUTATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGEN1'8 SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHIC 11116 PERMIT 18 ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR•0 AIRING OR SUB CONTRACTING SIGNATURE CERTIFIC TIIE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN't COMPENSATION LAWS O CALIFORNIA.' THE APPU MUti CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(20914410-S422. COMPLETE DRAWINO AT LOWER AREA PROVIDED. BIpnM X �— TRI. �.[ I -7 •� Ll- )LL.Z D.te /.X —� 7- PLOT PLAN(0—to S..1.1 80.10 'to 1. NAMES OF ST REEFS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR MIOPD6ED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSI EMB, J. DIMENSIONED OUILINF8 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WE118 WI1H1N RADIUS OF ONE HUNDRED FIFTY FT. STRUC1l1RE8,INCLUDING COVERED AREAS SUCH A$PAilOS,DRIVEWAYS,AND WALKS. ON TIIE PROPERTY OR ADJOINING PROPERTY. r ............. .i. .. .. J J t'.t If .. . ....... ...... ..... ... 1� .. . . : DEC 19 '99 mi JOAQUIN COUNTY _ PUBI 10 Hl-A:.THS°1 ,/ICES tNVIRUMNt£NTAI HEALTH UIVISI( DEPARTMENT USE ONLY App11c.11—A...plod BY ��,�- C -1r:J D.I. < A, V (iro.n In.pectl.n By D.te 5�,"pin.pecnen By j�� j�j,�/ (� U.Ie/ -2- �l /[' Ue•tn,cUen Lnnsotlon By � / to . ce,nn,m,t.: z1/-cy S 14 E c% s i '� TTK`-� ACCOUNTING ONLY: AID# FACT PE CODESFEE INFO AMOUNT REMITTED 11EC /CASH REC13VED BY DATE POWIT/SERVICE REQUEST NIIMB6T INVOICE +3� c) t)-s Pub Health Serv.-Enviro.173(1/97)