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APPLICATION FOR WELL/PUMP PERMIT O O SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ( 0 el ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NOWREFUNDARiE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED D Komplett In TFiplical.l \\��j/y//� APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICA7IO IS M N PLIANL It SAN JOAOUIN COUNTY DEVELOPMEN//T TITLE,CHAPTER 9-1115.3 AND THE n�STA NDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AUDRESSM11 APITN- �(r, <J [�' O "T/ ,-) ►GL CITY / % /�C(�' [ C?. L] 2(J PARCEL BIZEIAPNN OWNER'S NAME 4, Wim-�_ /+JY7— . � _ HONE t �SADOREei e CONTRACTOR 1. C�,S!/'L� pa`Ir%D J`E7 T`UI L' ADDRESS !JG ! LL/t �y/.�G�J15 EICN o RHONE I FUR COIYTMCTOA ADDRESS UC0 PHONE/ TYPE OF WELtMUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONPTORING WELL t ❑ OTHER ('� ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CAOSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J Flew❑m'.1, H.P. 2 DEPTH PUMP SET _FT. FIRST WATER LEVEL O [TYPE OF PUMP] ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL v ❑ SOIL BORING 8 y ❑DESTRUCTION: INTENDED USE TYPE OP WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM OIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O ❑ DOMERTICTNVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTFEt/PVC VIA.OF WELL CASINO O ❑ PUBLIC/MUNICIPAL ❑DRIVEFI DEPTH OF GROUT SEAL SPECIFICATION A ❑ IIIHIGAIWMAO ❑OTHER GROUT SEAL INSTALLED BY GISOUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yea 1114. CONCRETE PEDESTAL BY DRILLER:❑Yes ❑Ne S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE S PROPOSED CONSTRUCTIONIDWLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER II l I HE-EBY CERTIFY THAT t HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND 1 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't COMPENSATION LAWS OF CALIFORNIA.- CONTRACTORS HIRING OR SUR-CONT"CTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN't COMPENIIATION LAWR OF CALIFORNIA.- THE PPLIICANT MUt CALLL HOUR$IN ADVANCE FOR ALL REQUIRED INiPE/CT14�NS AT 12001464-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. �J 8foned Y, s(.�� v ((�//I!�'JL Title e e.1j47'C /— _ Dote PLOT PLAN[Drew to Soots)Sole 'to 1. NAMER OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY- 4. LOCATION OF HOUSE SEWAGE INSPODAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,OIVINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF OEWAGE DISPOSAL SYSTEMS, 3, DIMENSIONED OUTLINES 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 PFIOPERTY. I .... . f ptr l� �A.YP C . :.. : : .... JAI.. . . . . .a rGa� IN eGUI'l-T.Y.; . _. QNluit:NTALrHCttitTNrDIVSlt7N t DEPARTMENT USE ONLY -- ppllcetienAceepted-SY----^-- Arau [��y Grout lmpeetlan By ata Pump lmpeetlen By .{! Uffile 0—tnmctlon Ir pectlon BY Dela �k� r/ f Commm t.; . �� O tet^ Al✓UQ /` /'h r 4 1LZ LLA ACCOUNTING ONLY; AIDM FACT PE CODES FEE INTO AMOUNT REMITTED CHEC fCABH RECEIVED BY DATE PEiMITISETWICE REOUEST NUMBER INVOICE Pub,Health Serv.-Enviro.173(1/97)