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APPLICATION FOR WELL/PUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Campleta M TTbReata) APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-11115.3 ANO THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNS_ t1 3 1 w,,'l C f L1 y e, V'�A 1 �} J O(((�� 'A y CITY ��/p'1 �•` PARCEL 812E/APN/ 7 ^� OWNER'S NAME -/5 �7fC 4f(5 /oto C 1 100 ADDRESS �, S trt - 3,71/ S L d ^ PHONE I l 1441 i CONTRACTOR :'(,•''f L Jtl LD 10 FY1✓i ll'0 M I%Nl410� � ADDRESS 0�' !V• Tt'4QI^ W 11l UCs 'OQI'i 7 PHONE/ 14 17-t!'a6 AVS CONTRACTOR ADDRESS LIC/ PHONE/ TYPE OF WELLIPUMP, ❑ NEW WELL ❑ REPVUCEMENT WELL ❑ MONITORING WELL/ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CR088-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J ❑New❑Rgnk H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 TYPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL/ Q SOIL BORING S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS II A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONOUCTOR CASINO - p ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASINO p ❑ PUBUCIMUNICIPAI 13DRVEN DEPTH OF GROUT SEAL L SPECIFICATION R ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY I r- GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Y. [314. CONCRETE PEDESTAL SY DRILLER:Ely- ❑Ne d APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE s PROPOSED CON21 RUCTtOMMMLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER y( F b U I HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT M THE PERFORMANCE OF TILE WORD FOR WHICH TWO PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWINO: 'I CERTIFY THAT N THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 MOVED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOtMIND MSPWTIONG AT/(2661168-W22. COMPLETE DRAWING AT LOWER AREA PROVIDED. Btpned X Thle P r', "' (�I `)z 0,C:1 15 Oet• PLOT PLAN 0—to Sodel Sade 'to 1. NAMES OF STREFT8 OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. /. LOCATION OF HOUSE BEWAOE DISPOSAL SYSTEM OR V410MBED 2. OUTLINE OF THE PROPERTY,GIVING DIMENBION8 AND NORTH gRECTION. EXPANSION OF SEWAGE DISPOSAL SYBTEMB, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,RNCLUDINO COVERED AIEAB SUCH AS PATIOS,DRIVEWAYS,AND WAUUS. ON THE PROPERTY OR ADJOINING PROPERTY. t DEPARTMENT USE ONLY AppBeetbn Aeeepted BY Del. Arty O—A Impeatbn By Dets Imp Impaotlon BY 0.10 Oertntetbn Imva tlen BY Det. C emmeM� ACCOUNTING ONLY: AID/ FAC/ PE Coots FEE INFO AMOUNT RIEANTTED CNECKNICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE Pub Health Serv.-Enviro.173(1/97)