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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 F1013-REFUNDABLE PERMIT EXPIRES 1 YEAR FROG'! DATE ISSUED (Cemplat0 In TrIpHeatd APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE..CHAPTER 9-1 115.3 AND THE STANOARDB OF SAN JOAQUIN COUNTY1PUBLK:/HEALTH SERVICES.ENVIRONMENTAL HEALTH DMSION.. JOB ADDRESS/OR APN7 Z 7 I S ✓ /.//--/ 1017��J"Cl CITY/ / O C�./�-(��^ PARRCyEL SIZE/APN/ I ZJ UG 17-Z OWNER'S NAME_SJ / �n.�1 Y I P/I T �' ADDRESS [yQZ3 Z //t!"�a�� r�.Il e CONTRACTOR ✓ may/ '� / .17 ADDRESS r.O- /�C1X✓l- /v 0 t"-5'%UCf 7z"c/Q SUB CONTRACTOR q� ADDRESS UG PHONE f TYPE OF WELV �7o— PVMP: ❑ NEW WELL ❑ REPLACEMENT WELL yMONITORING WELL f Z ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL f J ❑Ha-❑Rgrdr N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL f ❑ BOIL BORING S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL �❑}OPEN BOTTOM DIA.OF WELL EXCAVATION C7 DIA.OF CONOUC TOR CASINO O ❑ DOME9TICMRIVATE I$GRAVEL PACKIBIZE_ /L TYPE OF CASINO/STEEL/PVC S'C� LIQ pL VIA.OF WELL CASINO Z 0 ❑ PU%LIC/MUNICtPAL ❑DRIVEN DEPTH OF GROUT SEAL P_0 0 �' Q _ �G) SPECIFICATION R ❑ fARIGATON/AO ❑OTHER GROUT SEAL INSTALLED BY n-�SROUT BRAND NAME �S'9 - } E W PAOMTOFUNG GROUT SEAL PUMPED: My,. [IN. CONCRETE PEDESTAL BY DRILLER:[1Y- ❑Ne S APPROX.DEPTH Q LOCKING CHESTER BOXISTOVE PIPE o� s PROPOSED CONSTAUCTIONID10LLNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HE9EBY CERTIFY THAT 1 HAVE PREPARED TH APPLICATION AND THAT THE WOW WALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF &JED4ALL JOA C MF OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18189NO PLOY RSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR 8UB-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: IFY T T MTI RFORMANCE OF THE WORK F-OR WHICH THIS PERMIT 18 ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPQIMTtON LAWS OF CALFO A.• ANT V T LL 24 HOURS IN ADVANCE FOR ALL REQUIRED INS TION* T 2"1 4OSJ4". COMPLETE DRAWING AT LOWER AREA PROVIDED. / 1/Il O , SW.d X _/ This i ! PLOT PLAN Kk M'to Se No)Soda to I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIV810 OIMENOIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. DIMENSIONED OVTLWF.S AND LOCATION OF ALL EXISTMG AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS OUCH AS PATIOS,DRIVEWAYS,AND WALX8. ON THE PROPERTY OR ADJOINING PROPERTY. -- .._ ..._. r r ......._....._..................... ..._.. G DDI' T USE ONLY Q�]. Appit-0—A".ptaNo d ey A f [7 O / f I A,w_iQ�� o.oul impeetlen By ./ / C' U l p Irnpxtlon By Durr D-f—tlen Irnpectbn By Orb ACCOUNTING ONLY: AID/ TACO PE CODES FEE INFO AMOUNT REMMTTED CHECK//CASH R ■Y DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 3J l q 9 Zo. Pub Health Serv.-Enviro.173(1/97)