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'NPPLICATION FOR WELL,/PUMP PERMI- SAK,-JAOUIN COUNTY PUBLIC HEALTH SEF,,,,,;ES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 MOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CoAPPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT lete f SRTRUCTA D/on INSTALL THE WOW DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TFTLE,CHAPTER 9-111 S.3,AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# 7 / -. �� ay y -G'5- OWNER'S NAME- 'fkl i f}.�_ '`-7 j/ � CITY_ PARCEL SjIZE/APLJ/_- J� -----� ADDRESS Z. ( r''�,/ / T.•� -sYAIONE# CONTRACTOR JTTi].(r. (�a/,' r "� fy.t,7 T. �t ADDRESS 1 (.� •.� / UC# �t7 PHONE OF SUR CONTRACTOR & R~7�C�� ADORE + ) "� •sPHO E� �'��G.Z.Z �-y —7 TYPE OF WELLIPUMP: NFW WELL ❑ REPLACEMENT WELL MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# 13 J New 11Repa1r H.P, DEPTH PUMP SET FT. FIRST WATER LEVEL R VPE OF PUMP) p 11OUT-OF-SERVICE WELL 11GEOPHYSICAL WELL# ❑ SOIL BORINGS ❑DESTRUCTION: INTENucu USF TYPE OF WELL CONSTRUCTION bPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION A DIA.OF CONDUCTOR CASINO p ❑ DOMESTIC/PRIVATE I_7 GRAVEL PACKMIZE TYPE OF CASINO/STEE DIA.OF WELL CASINO 7 i� 0 ❑ PUB(IC ❑DRIVEN DEPTH OF GROUT SEAL - - SPECIFICATION R ❑ IRRIOATION/AG ❑OTHER GROUT SEAL INSTALLED BY �T GROUT BRAND NAME E MONITORING GROUT SEAL PUMPED: ❑Vee [IN. CONCRETE PEDESTAL BV DRILLER:Ely- ❑No 5 APPROX.DEPTH LOCKING CHESTER.C!j�jOVE PPE / S PROPOSED CONSTRUCTION/DAILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER. A&Z. � I HEI%BY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAW8,ANDRULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEnM1T 18 ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUR CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' \1"I IS VILI1CA/NT MUST CC�JA�LL 24 HOUR6 IN ADVANCE FOR ALL REOUIRED INSPECTIONS AT 12061166-1123, COMPLETE DPAWINO AT LOWER AREA PROVIOF., Slo—A X �I V`i�%4 J4lf�s Tltle � Z�'� Do. �d/ PLOT PLAN IDrew 1.9o0e1 Soala to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. /. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPFFITY.GRANO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL 8Y81EM6. 3. DIMENSIONEO OUTLINES AND LOCATION OF ALL EXISTING AND PIOPOSEO e. 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 ? PAYMENT' ( 71VE AY 4.199 SAN JOAQUIN COUNTY PUBLIC HEALTH!SER VECES ENV CI M ENTAL NE:ALTM DIVISION IR lam= DEPARTMENT USE ONLY zz-_`T� L Mae Apnlloatlen Accepted By Grout Imoeetlon By Date P—p Inapeotlon By Date Date Oaalnrollen Imneetlen Br Comm A.: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#ICA6H RECEVEO BY DATE PERMIT/SERVICE FIFOUE6T NUMBER INVOICE Pub.Health Serv.-EnvirO.173(1/97)