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/?A'41 j , APPLICATION FOR WELL/PUMP PERMIT NOV 2 3199 SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION :JUNTY 304 EAST WEBER AVENUE, STOCKTON, CA 95202 SERVICES (209}4b$ 420 ENVIRONA+IENFAL HEALTH DIVISION NON•REFUNDARLE PERMIT EXPIRES f YEAR FROM DATE ISSUED (Complete in Trlptleatol APPLICATION 18 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY OEVELOPMENT 7rr ,CHAPTER 9-1 115.3 AND THE STANDARDS Of SAN•70AOUIH COUNTTYFVIBLIC HEALTH SERVICER.ENVIRONMENTAL HEALTH DMBION• JOB ADDRESSOR APN# CITY � PARCEL SIZEJAPNI OWNEA'8 NAME_�'�'t V�' �i rte_ -r..�V[rL�3 t t-+ ADDRESS_ L �1 " 1 ,7�.7 _.. j„�, PHONE I CONTRACTOR_ //��//'�,/,/'P,- ��C✓ 1�^L� 102 L ADDRESS 13� � C Y•u� 5 „L_ rrONE��IZ,s 31}'3-t�$ 7 RUB CONTRACTOR ' r s->v ADDRE68 © 2 }+ .plc, J PHONE E.�L.J 1 3" TYPE OF WELt1PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNEC7 REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑RepeH H.P. OFPTH PUMP SET FT. FIRST WATER LEVEL 4 {TYPE OF PUMPS41 C"Z� / 13 OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# BOIL soniNf7 i�!y+fir LO B 13OESTRUCTION: l5 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIIE TYPE OF CASINGISTEELIPVC DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL 1❑(yF4VEN DEPTH OF GROUT DEAL SPECtMATION R 1:1IRRIGATIONIAG IJ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yr [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr EI Ne S AP X.DEPTH LOCKING CHESTER SOX/STOVE POPE s PROPOSED CONSTRUCTIONIVAILL1N0 METHOO: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HMRY CERTIFY THAT I HAVE PREPARED THIS ATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOA COUNTY, E OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS IS ,I SHALL NO R,pV TJS SULIJE'T TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SU"ONTRACTM SIGNATURE CERTIFIES THE FOLLOWING: CE T AT IN tE ANCE OF THE WORK FOR WHICH THIS PERMIT IB IDSUEO.1 SHALL EMPLOY PEP-BONI SUBJECTKM TO WORKMAN'S COMPENSATION LAW8 OF CALIFORNIA.' T A C VST C IN ADVANCE FOR ALL REOUIRID IIN`SPECTIONII AT 1200}40111-11,11211. COMPLETE DRAWING AT LOWER AREA PROVIDED. TRIS PLOT PLAN Ovew to SeNal Seal* to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNOTNG THE PROPERTY. S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLIVE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. MWNBIONEO OVTLINF.S AND LOCATION OF ALL fXIVT*M AND PROPOSED S. LOCATION OF WELLS WIYWH RAOMS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. I I I . _ �1.�5,�. '��.E .:`!_�"T�•fi-NES : �'�T� .. ice`} _ I I t DEPARTMENT USE ONLY- i Appltenlert Aeeapted By pate !i A,..L--y.� Grout Impeellen of L All--e ` One/ qF'.p Impaetlen By Date Oeetntetlen tmpaetlen By One ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHtq(97CASH RECEIVED BY DATE PERMITISERVICE REOUEBT NUMBBII INVOICE ; °s Pub Health Serv.-EnYlro.173(1/97) �,.�