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PPLICATION FOR WELL/PUMP PERMI' SAIMAQUIN COUNTY PUBLIC HEALTH SERbfCES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON, CA 95202 (209) 468-3420 M0N•REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED-1 (Complete in Triplicate) J�'' l �y��jb�[YIQ s APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIAdCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN/ p©O ,�l�^�+ - L � � rd ►1l tL is'—f=- —CITY OS+ 15 C ki f e PARCkEL SIZE/APNE OWNER'S NAMIs. ADDRE6ONE I CONTRACTOR + t) 'sr'ea cr��` ADDRESS c Aa —_ �C+'vGx� I(1f�t�d-Iu n q CF ONEI �� SUS CONTRACTOR ADDRESS 7 U 0 V 'bY1 I S�Jr I c- y/� LIC0PHONE/ TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONrTORINO WELL+I ❑OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 13 J New❑Repair H,P. DEPTH PUMP SET (TYPE OF PUMP) FT, FIRST WATER LEVEL `may,/ O ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# til SOIL BORING hilt �^„O t ❑DESTRUCTION: III�" INTENDED USE TYPE OF �L CONSTRUCTION SPECIFICATI/OI��N,,S, y ,/� ❑ INDUSTRIAL ❑OPEN BOTTOM p `•, DIA.OF AW4L4V.Q VA;;4sN (Jc D I/�.t 8/� rV ZI I DIA.OF CONDUCTOR CASINO k./� /� A ❑ DOME9TICR'RIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC- N A DIA.OF WELL CASINO N A U y y 1 D PUBLIC/ . MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 1 0 4-p Q NL SPECIFICATION R ❑ IRRIGATION/AG OTHER Z :50ii b1DPj Aj9GRGuT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING V //1 a GROUT SEAL PUMPED: [I Yea ❑Ne CONCRETE PEDESTAL BY DRILLER:❑ ❑Vw Ne S APPROX.DEPTH 0 &116 (r� 2,S `6,vt s' LOCKING CHESTER 80%/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLi 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 BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTINO 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 CAUFORNIA,• THE APPUC T M T CALL 2 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120914"-3422. COMPLETE DRAW1NO AT LOWER AREA PROVIDED. d (^/' Slpned X P' col oa'i S—t !—30—-1 D Title PDQ Data PLOT PLAN(Drew to SoWel Sods 'to 1. NAMES OF BTREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On 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 WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. S .> a. "�aceec� �GLe I _ r DEPARTMENT USE ONLY Application Accepted BY - bIL rrte Arw Grout Inspeetlen By Dote Pump Inspection By Date Destrmilon Impaction ''BIIY C�'G%C,/n nomi_ '-� Y _ I Dote Comments: ACCOUNTING ONLY: AID/ FACT PE CODES FEE INFO AMOUNT REMITTED CHECKI/CASN RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 3501 $ is Pub.Health Serv.-Enviro.173(1/97)