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APPLICATION FOR WELL,/PUMP PERMIT, SA6%E,0AQUIN COUNTY PUBLIC HEALTH SE,„I,+CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468_3420 iq NON•pEFUNDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED r (Cenlplet9 in Triplie9t9) APPLICATION N HERE EL MADE TO THE SAN JOAQUIN COUI•TTY FO PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN# AP,J d 3 - 140-5-7 -5 4 5 CITY i--t-TD, CA PARCEL SIZE/APNI OWNER'S NAME �i C1�J�l.._ C"G'12tz fZ95Z.4o ADDRESS 54-5 �-r Lc)Di AjE CA PHONE# CONTRACTOR i�erltj �R,Iwt�^�-tr' 3f3y'Cr�svrt3¢�cy, t ADDRESS C UCI � 6 76 6 F T C- SUB CONTRACTOR 1n rGt7+�e r/,,2� Q�Le kI✓C PO� GP}HONE I_ ADDRESS 33 A2 -cA G,4 U57 7/c,0- / 7L-) PHONE I 13QW .1 2122 1 TYPETYPE OF WELt"MpIP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ INSTALLATION ❑ WELL SYSTEM REPAIR 11 CROSS-CONNECT REPAIR ❑ OTHER ❑ 11New 11 Repalr H.P. VAPOR EXTRACTION WELL I J (TYPE OF PUMP) DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B DESTRUCTION: �s�'t?EJ./T v�'j-13 PL vkc-g INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS�J� ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_ IV t.JG{ DIA.OF CONDUCTOR CASING A ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZED TYPE OF CASING/STEEL/PVC S--A 4.O py(_ DIA.OF WELL CASING .4 1, , ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION_ -Stitt ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY T.'L�.,,,,t/` GROUT BRAND NAME R E ONITOnING 1`(AP�41LJ _4 y-•-,ZA C-Tt_} GROUT SEAL PUMPED:,:�Vee ❑No CONCRETE PEDESTAL SY DRILLER:Ely- APPROX.DEPTH �-F'Y [IN. S LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER - I NM13Y 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 REGULATION$OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1$HALL 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 APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(2091/440-342?. COMPLETE DRAWING AT LOWER AREA PROVIDED. Blpned X_ /'//� 4 ey ,LING The &y!£c7 L 4 c..t�C/S7 Dete_ Cn•-Z�j'-,jg PLOT PLAN(D.ew to Sade)Bode 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,OIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. 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. t :....;......:......... .'... ............................ DEPARTMENT USE ONLY 7 Applleetloo Aeeepted By T V::!� bete ` Aree �-- Grout ImpeeNon By ✓�.-�/'I One Pump Impeetlon By �•^� Dete Dostrmtlen I-peetlen By Sete C/ ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 3 o Pub.Health Serv.-Enviro.173(1/97)