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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN 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 Mempk1E In Tr1pikatal APPLICATION 18 HEAE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.11 15.9 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNI Oa Ci Z12 2 ISOE Ayr, CITY Q PARCEL HIZE/APNI OWNER'S NAME G /S!��Y D 1.�6 S I�QeC� ,-ADDREsa .. G2Q 4S .- LO(J0-TC- . 4145 PHONE# &S g 42oZ. CONTRACTOR CON Dole EG+4L_r11 . r'C L404',I6Z ADDRESS/Irk P7-04141L WeC_r CP.LIC0 PHONE�_Z3{/o7SrI RUB COTlrRACTOR l l ADDRESS Ift,SO/{.S1 AM bo _ LICS^ _PHONE/. J�Ir.ZS�S ama�� ..a m urs f TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL. --9 ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROS"ONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑Nan❑%wei, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMPI ❑ Ouv�or mRvK:E WELL ❑ GEOPHYSICAL WELL of ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAJIONS A e ❑ INDUSTRIAL ❑OPEN SGTTOM DIA.OF WELL EXCAVATION S t GIA.OF CONDUCTOR CASING D ❑ OOMESTIC/PRVATE ❑GRAVEL PACKMZE TYPE OF CASING/STEEL/PwC P C1 DIA.OF WELL CASINO _l� +P _ D ❑ PUOUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL_ rte+ 0—,2' SPECIFICATION rjQy A ❑ tMOATION/AO ❑OTHER GROUT SEAL INSTALLED BY D le 1 LLC-4 GROUT BRAND NAME E fin MONITORING GROUT SEAL PUMPED: ❑Y. [IN. CONCRETE PEDESTAL BY DRILLER,, Y. [IN. S 1 APPROX.DEPFN -I -. _FEE._ ___ LOCKMO CHESTER BOX/STOVE PIPE a PROPOSED CONSTRUCTIONIDISLUD LMOMETHOD: MROTARY Am ROTARY AUGER - CABLE OTHER 1 HE9EBY CERTIFY THAT I IfAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE Wrr"SAN JOAQUIN COUNTY OROWANCES.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 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TG WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SIRS-CONTRACIN G MINIATURE CERTIFIES THE FOLLOWING! '1 CERTIFY THAT M THE PERF011MAYCE OF THE WORK FOR WHICH THIS PERMI'T IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIOMAN'S COMMFTISATION LAWS OF CALIFORNIA.' THEAPPLICANTMUST CALL N ADVANCE FOR ALL REOUIIIED INSPECTIONS AT 12001 MI!-5422. COMPLETE DRAWING AT LOWER AREA PROVIDED. ft,.d / Title sem/✓/C?JL r-s e'.OG Dog LC T• Dole PLOT PLAN(Draw to Sold Beal. 'I 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE 01SPOM SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GTVM DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL BYSTEMS. ]. DIMENSIONED OUTLINES AND LOCATION OF ALL EXWMM AND PROPOSED S. LOCATION OF WELLS WITHIN RAMS OF ONE RUMORED FIFTY FT. STRUCTURES,INCLUDING COVERED A14EAO SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJO"W PROPERTY. �itryT/O.,/ ..... ..: . .: Gv!II''TETC tJ AL�. .'..,�p r✓.r�ot, Li'�i¢a�', Applealln Aeeepled By11"W. -NV' up-L, OEIMTMETUSEONLY --- —- Oafa_ 'e1� Mw Grein ln.peallen By Data Pu o'fr"mrtan By Dal. De.lnrellan Impaellen 0 13616 I:ernms+•!---fie E�[1Q.,A rIhJ 1, E� L , _.fit_�lC�lhll t�rau .......—.,_,_.._-- r ACCOUNTINO ONLY: IUD& FAC/ PE CODES FEE INTO AMOUNT REMITTED CHECKR/CASH RECEIVED Ey DATE PEFMITISEIIVICE REQUEST NUMSER INVOICE A C90 Pub Heatth Serv.-E=nviro.173(1/97)