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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION RECEIVED P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 (209) 468.3420 J U L 17 1995 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH IU is TripliaUl Ik ERN L�f� ©, APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AP AND/OR INSTALL THE WORK DESCRIBED.THIS 1 �dIG JOAQUIN COUNTY DEVELOPMENTT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. WITH SAN JOB ADDRESS/OR APNar �j I/F� {p/ �¢�66! CITY PARCEL SIZE/APN " O VNErCi'S NAM nJ - Gs-...` n 77 ADDRESS v�SH' 0-44W ACh •""'t.THONE M 17 CONTRACTOR ; �r o-0 �,y,�._Or,��. J �,.,�( ADDRESS I , rY►- # l SUB CONTRACTOR 1 S I1D(�� o f -PHONE f/��y��(j Q C �JDd� ADDRESS 7�Z� LICE PHO 7 TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL A ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# / ❑ (TYPE OF PUMP) New 13Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL Ir ❑ SOIL BORING _ B • DESTRUCTION / /fjg-s-,. Xj C"77r/� " J ( J11 CoY1 --1, we'), —. - INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION „ DIA.OF CONDUCTOR CASING —� p ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC //V C DIA.OF WELL CASING "7t4 ; i-I ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL_ S SPECIF)CATION r7 ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME C'�N111G1 JarMONfTORING GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER:❑Yea ❑No S J' APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY_ AIR ROTARY AUGER_ CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION 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 IJCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE_ CANT MUST CALL 24 HOURS IN ADVANCE3 IFOR ALL REQLARED INSPECTIONS AT 1209)499423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X(/[ .t'�_ Title �-7 Date PLOT PLAN(Draw to Scale)Style '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 IWELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS.DRIVEWAYS,AND WALKS. ON THE PROPER-iY OR ADJOINING PROPERTY. .............:...............,............................. :......'.......:.............:..... .. ... ... ... ... :.. ..:.. ....................................:......: ;. : . - . DEPARTMENT USE ONLY Application Accepted By Date O / Area \ Grout Inspection By Date Pump inspection By Date O Destruction Impecti Date c� Comments ACCOUNTING ONLY: AID* FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK*/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE K c id /0 tomw —1007 9 Lool"11--mw �N