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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388,445 N.SAN JOAQUIN ST., STOCKTON,CA 95201388 (209)4883420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1CompMts is Tripl[eatel 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 with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. 7 /[ l Job Address/or APN# CCI01L VAI) AATO� 2 S100f� City dpL'r Parcel Size/APN# nn ��&IAL£ AAdress KS_-v�,H >'YbAJ C)CGGT1-7 Phone #17)3Owner's NamSnTTA YuF,( ^Yu7 ,7 n Contractor �gLCV-�`C"7 5k:W--4IA �Sott_("S) Address 3�N-DVS L7i5,QI/l'1yLic# Iy1r711, Phone 01121-ffl Sub Contractor WNA/l; 0l2-(LA1A/j! Address�0.6N 711LI L(NIDTff(o Gx) Lic# 37JJ47 Phone #41C- TYPE OF WELL/PUMP: )k NEW WELL ❑ REPLACEMENT WELL �(,MONiTDRING WELL # OTHER 601L-CA-,�, [I DESTRUCTION ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # ❑ SOIL BORING [3 INSTALLATION [3 WELL SYSTEM REPAIR [3 CROSS-CONNECT REPAIR [) VAPOR EXTRACTION WELL # [3 New 13 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL (TYPE OF PUMP) INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS [] INDUSTRIAL (I OPEN BOTTOM DIA. OF WELL EXCAVATION ID IN DIA. OF CONDUCTOR CASING NIA [3 DOMESTIC/PRIVATE X GRAVEL PACK/SIZE-4c--.3 TYPE OF CASING/STEEL/PVC FG- DIA. OF WELL CASING /N eH (I PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEALIC) 6--V7 SPECIFICATION CC'Y4,,11- IRRIGATION/AG [3 OTHER GROUT SEAL INSTALLED BY.t'JMA\C/677r YYW GROUT BRAND NAME j�MONITORING GROUT SEAL PUMPED: [3 Yes K No CONCRETE PEDESTAL BY DRILLER: [3 Yes O,No APPROX.DFPTH_ LOCKING CHFSTF.R ROX/STOVE PIPE. PROPOSED CONSTRUCTIONIORILLINO METHOD: MUD ROTARY_AIR ROTARY_ AUGER CABLE_OTHER_ I hereby certify that 1 have prepared this application and that the work 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 rmit is ass ed, I shall employ persons subject to WORKMAN'S COMPENSATION Laws of California.,. THEAPPLICANT MUST CALL 24 HOURS IN ADy E FOR ALL REQ I INSPECTIONS AT(209)499.3423. Complete drawing at lower area provided. Signed X Title fllT've'PI}(- 4))11t1rtb(-U(-IJ) Date 0 31�G�1 LOT PLAN (Draw to Scale) Scale •• to 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or 2. Outline of the property, giving dimensions and North direction. proposed expansion of sewage disposal systems. 3. Dimensioned outlines and location of all existing and proposed 5. Location of wells within radius of 150 ft. on structures, including covered areas such as patios, driveways, the property or adjoining property. and walks. _Is •R SrPP PIPELINE FORMER SrPP PIPELINE ARCADY OIL CO. "-. J • r.l,..n.,,..n x AGRICULTURAL rIELD X x FI,- 2 x SITE PUN SNOWING SOIL-GAS/GROUND WATER so loe rTn •�-e SURVEY LOCATIONS 3A�--DEPARTMENT USE ONLY 4 /} Application Accepted By 94 Date ` l3 Area Grout Inspection By Date PLnp InJ4,1ection /By /� q Date Destruction Inspection By Date Comments: II Work Alm 6N 13)-016 —1� ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECKTICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE