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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 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICemplete In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1115.3 AND THE STANDARD OF BAN OAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. �y//�y•' �rAc+ �• JOB ADDREE91,0R APN#( waA)y! AG r.y�l c�r�Y d kiA,/� CITY.. L PARCEL BI2EIAPN0 OWNER'8 NAME yGw(//i 1�!1S C,..„r-I.^ ) , veli ti ADDRESS rlI�.1 �. /�9NAI TC�'�IJjZ 1/�/'- PHONEI ZOZI y(R; L✓cz CONTRACTOR CC. LJC `, ^O R9 RC . ADDRESS CQ. 'l/ YVIr S'7< �WPI� UCB 01� Zp�yZ ,MNE# zcci Y(�y[II1Ot�� sue CONTRACTOR f "Y, �'//I 'I4 _ADDRESS C•/ &� JL.JIR tK:# J ( PHONE I I14' &5S?LZt TYPE OF WELUPUMP: V NEW WELL ❑ MpL CEMENT WELL MONITORING WELL IVJ_tL ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J ❑New❑Repelr H.P. DEPTH PUMP BET_”. FIRST WATER LEVEL O ITYPE OF PUMPI ❑ OUROF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ BOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTOM ¢ c DA.OF WELL EXCAVATION I C i'%L H DIA.OF CONDUCTOR CASING H A//A D ❑ DOMESTICRRIVATE RAVEL PACKISIZF I� M" ?414 TYPE OF CASINOISTEE5! >DUL DIA.OF WELL CASINO of " 1 3Ui�) D ❑ PVBLICRAUNICIPAL ❑DRIVEN DEPTH OF GROUT SEALCluL`�n C PJM SPECIFICATION�I0•'i4 Y B ❑ IRRIGATIONFAG ❑OTHER GROUT SEAL INSTALLED BY I r E IPH r— GROUT BRAND NAME G R P J A,NiD £ AMONITORING GROUT SEAL PUMPED: grvP ❑Ne CONCRETE PEDESTAL BY DRILLERAY. [IN. a APPROX.DEPTH i rJo FEki 6�cr LOCKING CHESTER BO%ISTO� S PROPOSED CONSTRUCTIONIDHO ULLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLEL OTHER 1 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 BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF TIRE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMANY COMPEIItAT1ON LAWS OF OALIFORNIA.- CONTRACTOR'S HIRING OR BUR CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORMr1AN'6 COMPENSATION LAWS OF CALIFORNIA.' NF APWCAM((i MUS11T``CALL SA FIOlme IN ADVANCE FOR ALL RFQURED IRtRCT10Nft^A/�T If081 4pJ111. COMPLETE DRAWING AT LOWER AREA PRGNDED. eltned% �(�/ THIS �%A F-f(TF j o i S� Del. �- 7—gr MOT RAN Mrrv.IP SPYBI Svels 'IB 1. NAMES OF STREETS OR ROAOB NEAREST TO OR BOUNDING THE PROPERTY. #. LOCATMN OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLDF.B AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RALNUB OF ONE HUNDRED FIFTY FT. STRUCTUMB,INCLUDING COVERED AREAS SUCH AS PATM$,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING P DPERTY. APPSvellPn AeaePled By DEPARTMENT USE ONLY Grvul I—P-11l By D.N Pune lnePPvBen 8y D.I. Owbuetlen ImP.nllan Oela_ CvmmreA. v� Dui- .- ACCOUNTING ONLY: AID# FACE PE CODES FEE INTO AMOUNT REMITTED CHECK#ICABN RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE Pub.Health Sew.-Enviro.173(1/97)