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SPLICATION FOR WELL/PUMP PERMI-S SAN AQUIN COUNTY PUBLIC HEALTH SER MES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplkalel APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WNIt 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 APN/ n 26S,76 1g 41y*rA 9,U 14-P Cl//TY_ -rp 4 mC y /� PARCEL SIZE/APNM 252--15c) -6s !' OWNER'S NAME M R. L-F2G D Pa M a 6 ADDRESS V(04S W. .VELI,4 A✓F-, -r"CJ1t/PHONE 2,o3 3S L)Z Lo CONTRACTOR_WE-pr 1-t4ZMRT D/ZrLIL/NG AbDRE8S3L33 FITZ Gtfp QD !uc� S4 �q PHONE /b &9fd 12N SUBCONTRACTOR ADDRESA4NLH-, (-ANvj1 `S•MZ, (( UTICA,' PHONE` 7 TYPE OF WELUPUMP: 11 NEW WELL ❑ REPLACEMENT WELL MONITORING WELL.M 6 P.OTHER IT 7D/Z��✓NC� ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I (TYPE OF PVMPI 11Now 11 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL 0 ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS / A El INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION q n�G•A1 8—/ DIA.OF CONDUCTOR CASING D ElDOMESTIC/PRIVATE ❑GRAVEL PACKMIZE TYPE OF CASINO/STEEUPVt2C 2" !"✓G DIA.OF WELL CASING ❑ PUBLIC/MUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL S�, (» SPECIFICATION S ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME_ J!' _ «� f t- MONITORING (' ^� d/(h IF GROUT SEAL PUMPED:*Yea (I No r CONCRETE PEDESTAL BY DRILLER:[3Yaa CIN. S APPROX.DEPTH -3J LOCKING CHESTER BOX/STOVE PIPE /';�-�1 S PROPOSED CONSTRUCTION/DRILLINO METHOD: MUD ROTARY AIR ROTARY AUGER__CABLE OTHER 1 HERERY CERTIFY THAT 114AVE PREPARED THIS APPLICATION AND THAT THE WORK 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 AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEN6ATION LAWS OF CALIFORNIA.' HE PUCAN MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INJJJJ E�C�TION$Aj 120014 -3422.. COMPLETE DRAWING AT LOWER AREA PROM EED. / Slprwd% ��a *� Title ( / J,'R.�L?.G'�.�.- Date PLOT PLAN(Draw to Scale)Seale '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 DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. 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. .......... ...•. ..;.... .. .. .. ... ..'....i.. ......i :...... ..... .. .. �/ _ _. I.. .�.� •_a ....... ..... ;.....i ... ...................... _.;.... _ ..... _.: ".....:.....i..... .....i......F..... ......... .. ....... �I DEPARTMENT USE ONLY Appllcetlon Aearpted'Oy M'�'"e� Gets r -�-�- Ororn InapeGlen By Date Pump Impaction By Date /'{ �T'"'�v`"�� ` bminr.11en Irnpm.Ion By bate 1 Lll•_ tI y Ale LO ACCOUNTING ONLY: AID# FAC/ PE CODES FEE INFO AMOUNT REMITTED CFIE 11 ASN RECEIVED BY DATE PERMIT/SERVICE REQUE6T NUMBER INVOICE Pub.Health Serv.-Enviro.173(1/97)