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APPLICATION FOR WELL/PUMP PERM`. SANJAOUIN COUNTY PUBLIC HEALTH SEI SES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON , CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER (CamPNb In Ti4JieatB) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK. DESCRIBED. THIS APPLIC A f1ON IS MADE IN COMM IANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TET F,/CHAPTEERR `9- 1115 .3 AND THE (STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SFFIACES, ENVIRONMENTAL HEALTH DIVISION, JOB ADDAESSMR AAM# z0I�O 1�L. Ic'/�Y�Ll1'I..;T': J CITY ✓ rrC�/�j"7�., PARCEL SIZE/APNC OWNER'S NAME '4 c -lk c, �]+YLa/s1 /vt-cs 1. ADDRESS ZVSV PITON[ t CONTRACTORg/(KM W! L/l �f/ c 9 L.c7 �y � ADDRESS O. p � 'c,E 7 "E O ;�a_Ef'�cr 7/607 ? ri wtk&Z7) mY et. BVB COMMCTORvirol ADDRESS LICi PHONE IF TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL IF ❑ OTHER a ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL B NIP ❑ New ❑ Aeoalr H.P. DEPTH NMP SET_FT. REST WATER LEVEL O TYPE OF MMPI ❑ I1pCOUT-OFSERVICE WELL ❑ GEOPHYSICAL WELL rII— INS SOIL BORING S ❑ DESTRUCTION: INTENDED USE T----YYYPE OF WELL CONSTRUCTION SPECIFICATIONS C� A El11 INDUSTRIAL UOPENBOTTOM �j DIA. OF WELL EXCAVATION J DIA. OF CONDUCTOR CA6INO A�ff f ❑ DOM /P ESTICRIVAT ® RA E GVEL PACKASZE•k° S TYPE OF CASING/STEEIIPVC -so[ (�y YO /` Vl VIA. OF WELL CASRCIIG '' '' Z'vI D N ❑ RUCIMIUNICIPAL ❑ DRIVEN DEPTH O OF GROUT SEAL � I SPECIFICATION SJL + 5pr /o SAG- B ❑ IRRIGATIONMG ❑ OTHER GROUT SEAL INSTALLED � BY ')^/•a'-lKi� GROUT BMNV NAME /✓ p fr MONITORING GROUT SEAL PUMPED: ?gym ❑ No CONCRETE PEDESTAL BY DRILLER: ❑ Ym ❑ No 5 APPROXI DEPTH BOO LOCKING CHESTED BOXISTOVE PPE 5 PROPOSED CONSTRIICTIONIMSWNG METHOD: MUD ROTARY AIR ROTAFRV AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION 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 AGENTS SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TMS PERMIT IB IRnUED, l BIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIVING OR SUB-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING- ' I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOA WHICH THIS PERMIT IS IBRUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORXAIAN'S COMPERRAOCN LINWB OF CALIFORNIA: THE APPLICANT MUST CALL 24 MMS IN ADVANCE FOR ALL REQUIRED IN j� AT 1201114"9) , COMPETE DRAWING AT LOWER AREA PROVIDED. 7P! cy Title (,, cf/U 6.� (— Date_�� l�/ PLOT PLAN IDrew to Sealel Scale • to I . NAMES OF RUMFEES OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE BFWAOE DISPOSAL SYSTEM OR TPOIOBED 2. OUTLINE OF THE PROPERTY, GIVING DIMFNSIONB AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. :1. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUMMED FIFTY ET. STRUCTURES, INCIVOINO COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WAMS. ON THE PROPERTY OR ADJOINING PROPERLY. DEPARTMENT USE ONLY 1 ' Auulloollo0 AoamtM BY �) n 1/'J ,{j Dole Arm �j Ovoid imooellen a ( n � DSte Pump Impaction By Dale Z Z 4 �'�M NVMM A 1 Dal Cemmewea: VAP a ACCOUNTING ONLY: AIDIF FAC! PE CODES FEE INFO MOUNT REMITTED CHECKr/CASH RECEIVED RY DATE PEAMITISERVICE REQUEST HUNDRED INVOICE L Pub. Health Serv. - Enviro. 173 (1197)