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SWAPPLICATION FOR WELL/PUMP PE OAOUIN COUNTY PUBLIC HEALTH VICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) 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 COMPLIANCE WNII SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNI_C,,,U Yt,'� � r 1`lk �, CITY I+TJ it PARCEL SIZE/APNA' OWNER'S NAME. .-SF(I^ L h ADDRESS((L U ILi-,�.� -t L,n�Y C l _PHO NE/LI� Sham:• `�`';�`� CONTRACTOR I`r�,^Sc.l�`7„ I S✓1v.r �t„n,.,.,'tcl (]c > V\ r 4t , ADDRESS ,-tt cnt..� Fes.-l• Nlw:- I ---7 �•., _ , „U e: e yk UCI t'A 71:(;��Ir�PHONE I\I((•J L�.i YJLtI.:. SUB CONTRACTOR ADDRESS UCI PHONE I TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 7 J ❑ (TYPE OF PUMP( New 11Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ Ol/T-OF-SERVICE WELL ❑ OEOPIIYSICAL WELL✓f SOIL BORING Ci t^ R ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTAUC71ON SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING n ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING p ❑ PUBLIC/MUNICIPAL ❑OnIVEN DEPTH OF GROUT SEAL >`r,.,r TP t., .i-.;*i,,., SPECIFICATION lk.;,'Y u---A R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY 0- i”— GROUT BRAND NAME �T�y� E ❑ MONITORING II GROUT SEAL PUMPED: q Yea [I No wJ Tf C—�<-r.�' CONCRETE PEDESTAL BY DRILLER:❑Yea Y?No S APPROX.DEPTH r I Z 7t. 1, LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Cit 1 HE9EBY CERTIFY THAT I I4AVE PREPARED THIS APPLICATION AND THAT THE W0W WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF TITS 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 IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' T PPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091469-U23. COMPLETE DRAWING AT LOWER AREA PROVIDED. Sloped X S�C:-t U-141; I Title �•:c.�{'1 V<✓ll�;.��i-��.� 1l (,� Date i I - PLOT PIAN(Draw to Scale)Scale 'to 1. NAMES Or STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL 8Y8TEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. i f . . . _..... .... .... . .. . . . . . 1 I / ygDEPARTMENT /USE ONLY -7 APPIIeatlon Accepted By_ -�`r r�K-iGK-L�-C `•-�C Ll 1 '^�` `.'—� ` Data '�:}� /�j� Area Grout I-poctlon By Date Pump Impaction By f Date DeatrueUen Imp tlan By �'�.r LJI - 1/L(,(.ti.y-.,,f.'C¢-_{' Date / -h3/5J' C.--W S � h [�i-7i 'V L 7 1 )j ACCOUNTING ONLY: AID# TACO PE CODE$ FEE INFO AMOUNT REMITTED CHEC-01CAS" RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 3U;- 7G'177 S Pub,Health Serv.-Enviro.173(1/97)