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4PPLICATION FOR WELL/PUMP PERMI- SAhijwJAOUIN COUNTY PUBLIC HEALTH SEmwtCES -' ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES f YEAR FROM DATE ISSUED {Complete in TrIpRpBtNI APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.711I8 APPLICATION IS MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11115.3�+A7ND THE STANDARDS OF IANJOAQUINCOUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORESSIOR APNI y2 w- A D�/ ri 1S ec o go R''d�j+P7 CfFV log yQ I?z r PARCEL SREIAPR# �j OWNER'S NAMES//� %-VJ442V1'1v dfd}VI J��f7- S' �.5¢!///%y A 84OW-vet *7?,O 7- S, Ap1P,/119W _.PHONE I '4 C- )U CONTRACTOR !�/tY�6��!i✓�Q�17 JlIG/<</+� G C d_..f��AdnBE6e .3 6/r J �C*Jy�04, 7106')!9PHO�q, y'y'93.00 �ys'7i SUB CONTRACTOR -t ADDREBB LIC• PHONE# TYPE OF WELUPUMP: IJ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL it ArOTHERPIG ESS uPL` Q INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL t J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D (TYPE OF PUMPI ❑ OUT-0r-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL ROBING R DESTRUCTION: LkSSg 6RO#'; INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION/NW'y'�__ M rI-.3 DIA.or CONDUCTOR CASINO D © DOMESTICAIVVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEELMVC we- DIA.OF WELL CASINO D © PUSLICOAUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL.13' • 1F *S,1mr SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROAT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MOMTOMND GROUT SEAL PUMPED:O Yr ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yw []No 5 APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONBTITUCTIONMAILLING METHOD: MUD ROTARY AIR ROTARY AUGER_ CABLE OTHER 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THI8 APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 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 1N THE PERFORMANCE OF THE WOgC FORWHICH THIS PERMIT IS ISSUED,1 SI#ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Or CALIFORNIA.' CONTRACTOR'S HIRING OR IUD-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,t SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'TTHE EAAPPLICANT MUST CALL 24 HO S IN ADVANCE F REoIARED INSP%C IONG AT 1201111441111442S. COMPLETE DRAWING AT LOWER AREA PROVIDE'. Slpry,d X_ /i7/Gs� Tltls_ 4Cy f�y�i L� /(r �`.,. -- -Data 1 l &7 7 PLOT PLAN Rhew to Reveal Scale '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. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WFTHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,ANO WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. Lam=. --- :.....:. ....:. '.. ... ...:.... ...:...... ...6...,.;.....,.......;..,...i..... ..,.:..,.,.. .......1......:............:......:. .. r DEPARTMENT USE ONLY 11-21-r Apppes0evn A.eeegtad IY Dala MM Grout kreve don By Date Prmp Inapeotlon By Data Aeatnmtlon Imvwtlon By Dots ACCOUNTING ONLY: AID# FACT PE CODES FEE INFO AMOLINT REMITTED CHECKOMASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE 3b Pub.Health Serv.-Enviro.173(1/97)