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( APPLICATION FOR WELL(PUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES'' I ENVIRONMENTAL HEALTH DIVISION J WEE P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA M201388 ■�f.' (209) 468.3420 �=` v NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEAM 10: J I (Compl9t9 In TripRe9t9) APPLICATION 19 IIERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOA ADDRE33/OR APNf !y(''7 G�� ign- Ll'i �STlI`t �— CITY ,�T��,��j� PARCEL SIZE/APNf OWNER'S NAME ' )J i Y ` ,...�• r l/ t�� ADDRESS /0 1%.Vr. �G i gACgp 6tp%}O PHONE f /� 'Z�L CONTRACTOR Y S G c I /i✓L/sem— •AbDRE96_D. `�/,R`,� ST,¢I/Il� UCf J;�jC,) PHONECA?V,5 SUR CONTRACTOR ADORE SO LIC-I�-�= —�-- PHONE 1' TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL f ❑ OTHER ❑ INSTAI LATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR bi VAPOR EXTRACTION WELL I� ❑New❑R-1, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL (TYPE OF PUMP) �—_.._ O ❑ OUT-Or-SERVICE WELL ❑ GEOPHYSICAL WELL f ❑ BOIL BORING B ❑DESTRUCTION: INTENDED USE - TYPE OF WELL CONSTRUCTION SPECIFICATIONS - -- A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION � ,�[�L./ DIA.OF CONDUCTOR CASING D ❑ DOME971CIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVCv�_ DIA,OF WELL CASINO O ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAiS FE&-7— SPECIFICATION ❑ IRRIGATIONIAG JRrOTHER GROUT SEAL INSTALLED BY ✓�(./! GROUT BRAND NAME Q E ❑ MONITORING GROUT SEAL PUMPED: ❑Ye• ❑No CONCRETE PEDESTAL BY DRILLER: Ye• ❑No S C APPROX.DF.PTN. Zj— �1� l'j LOCKING CHESTER BOX/STOVE PIPE 5 V PROPOSED CONSTRUCTIONIDWLUNG METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER I HFRFRY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RVLES AND nFGUTATION9 OF THE SAN JOAQUIN COUNTY, HOME OWNFn OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH TRIS PERMIT IS ISSUED.I SHAI L NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S 1411VNG OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLI.OWIN0: '1 CF FY THA IN THF PERFORMANCE OF THE WORC FOR WHICH THIS PERMIT to ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'/COMPENSATION LAWS OF CALIFORNIA.' T C NT M tT CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001469-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. i PLOT PLAN(D,—to 8-1.1 Fio•I•�_ 1. NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMFNSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTVnES,INCLUDING COVERED AREAS SVC"AS PATIOS,DRIVEWAYS,ANDWALKS. � ON THE PROPERTY On ADJOINING PROPERTY. .rt As"A x AREA O IZo cb VW- AAsus -� t, J r04we.Ri rA4< '` 6 Lo Wa*R�CNou,SE �LI�I�� 40 t ............................................................ __........... _. DEPARTMENT USE ONLY I / Applleetlen Aovepled Byim b•le + Are• Grout Impee Don BY Dote Pump Inspeetlon By O•te DMnrr:t1.n Impn.alon By O•le C.--tc ACCOUNTING ONLY: AID# FACS PE CODES FEE INFO AMOUNT REMITTED HEC /CAB" RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE )) Z i 2 Pub.Health Serv.•Enviro.173(3/96)