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�%PPLICATION FOR WELL/PUMP PERM'` SAN-wOAQUIN COUNTY PUBLIC HEALTH SEi.�CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED tIre APPLICATION 1814ERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONST�RUCTAND/On(INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRII SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN# ZZ- S t'A-lam CITU PARCEL 812E/APNp OWNER'S NAME el-T ( of 1-p D l j �i Lll �/cR•I REBS 27.1 WAC `I 5741 PHONE# Z-07 33;-'706 CONTRACTOR EM 4,;,,J — PI—NAI L.L"- G.•Q.+n tilt P AODRE883 C SUBCONTRACTOR L✓C.2.)f7lA.,.. t ps AbDRE88 (1LJ 1`�,� �/,y U'S7 �If.X77/ `7v7 — A PHONE# ��¢e� � TYPE OF---FLV%JMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL Or -1 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# 11 J New L1RepairH.P. DEPTH PUMP SET FT. FIRST WATER LEVEL (TYPE OF PUMP) U 1:1OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# 11 SOIL BORING B DESTRUCTION:_ DRlt.l. r iT EtLT.LALTi w7 J L./CLVW 6 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS p ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION S l N(aA DIA.OF CONDUCTOR CASING1.1., D ❑ DOMESTIC/PRIVATE GRAVEL PACK/SIZE_g 3 SLe.�D TYPE OF CASINO/BTEEUPVC St:t J hV G DIA.OF WELL CASING 4 i N CN D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION Sty Y py L R ❑ IRRIGATION/AG 11 OTHER GROUT SEAL INSTALLED BY 4.nt tGROUT BRAND NAME E MONITOIUNO I V!{Po2 F 7�T2ALT1o..� GROUT SEAL PUMPED: Ys ❑No CONCRETE PEDESTAL BY DRILLER:❑Yea []No S APPROX.DEPTH_ �(e FT LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLINQ METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER - I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB 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 1200)469-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. stoned X _ �t�1r�s /�-ir� Title 1?014[% 4 -15'7 Date 6'Z4 "1f3p0 PLOT PLAN(Draw to Soalel 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 OUTLDIEB 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 / / c�4M�� Appllcatlen Acoeeted By ' L ` net. -7• /` Area T/ Grout Impeotlon By Date Pump Inspection By Date I Deatnmilon Impectlon By j/(/1QDM ��}} 22 Date I Cemmenla• V ) -` `- "'" ` d'd t S ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED SY DATE PERMIT/SERVICE REQUEST NUMOM INVOICE K9q8 Pub.Health Serv.-Enviro.173(1/97)