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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Carnplete IB TripRaate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE W"M SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR /IAAPN/fJ.J�n(.J,1/ 5-.t/j� A7agrow C CIN �idC�SCI�A` ,y /� PPA�RRCyEL�JSIZE/APNI / OWNER'S NAME!/�Z1ME/C,14.,/i✓I'_• ' /i/' "�.-TI�7 Al)oREBB�iJ��LI�IL/1�•. & VELAND ey TT f�"f' PHONE r7 r LIGI V1=&:t / 'T1 7JQF CONTRACTOR Z /1J7 LN(1ZAieEtfr6S0 7JCE WL AVDRFee 0,14JkI& (-'j' a(yZy ucI PHONE/ ifawia [•� C57 SUBCONTRACTOR 6,L& /NC :' 7 PHONE 02 • (Stv)30•3- TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ 11New 11Reach H.P, DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF P'UMPI �,i 11OUT-0F-SERVICEWELL 11 GEOPHYSICAL WELL I ❑ SOIL BORING _ S *DESTRUCTION: 4AJ6V4 MW-S & OVEO!'.1/1_i N('> r 61z'OU-1 Spc;p-.S INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CARING/STFFVPVC DIA.OF WELL CASINO ..tI O ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAMEt/ _–�j j/•� E ❑ MONITORING / GROUT SEAL PUMPED: ❑Yee []No CONCRETE PEDESTAL BY DRILLER:❑Yea ❑Ne S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONTTTT/DIIILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE-tEBY CERTIFY THAT I NAVE PREPARED THIS APPLICATION AND THAT THE WOW(WALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND nEGLILATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED.I SHALL NOT EMPLOY PERSONS MIBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOFIRMAN'e COMPENSATION LAWS OF CALIFORNIA.' T APPLICANT MUST ALL HOURS IN ADVANCE FOR ALL REQUINIED INSPECTIONS AT 12001400-2422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X TitleDate 3 -� PLOT PIAN IDI—to Saelel Sade , 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMER MNS AND NORTH DIRECTION. EXPANSION OF 8EWAOE DISPOSAL SYSTEMS, 7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTUREB,INCLUDING COVERED AREAS SUCH AE PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ... ..... h/ �77U Q PAYMEN e RFC. w : ..:....:... .:. ..JUN 5 199$ . SAN IOAQUIN COUNTY ENVIRdNMENTAL HEALTH EIWpIV SIt1N 09t DEPARTMENT USE ONLY y Application Accepted BY/ tilil�d/G- '��7Y Date Zo / / _Mee aT. Grout kopeetlen By (�/i/�1 � Date - /,11/�,Pump Ineoeetlan By Date Deawntlen Impaction By Datee / p! 41172 ACCOUNTINO ONLY: AID# FACT PE CODES FEE INFO AMOUNT RQNITTED /CASH RECEIVED■Y DATE PERMIT/SERVICE REQUEST NUMBER INVOICE Pub Health Serv.-Enviro.173(1/97)