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APPLICATION FOR WELL/PUMP PERMIT SAN JOAOUIN 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 (Com kid APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONS 7RUICTAND1Oit R INSTALL THE WORK DESCRIBED.TF119 APPLICATK)N to MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENTTITLE.CHAPTER 8-1118.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLICICE HEALTH SERVICES,ENVIRONMENTAL HEALTH DMMON, JOB ADDRESS N APNI 11055 N. St. Ht%ry 88 CRY Stockton PARCEL St2E1APNl OWNEA'S NAME 11 t Pete Paras ADDRESS 11055 N. St. Hwy 88 Stockton PNONE r 368-7337 CONTRACTOR JIENNIPIGS BR S. DRILLING CO. , INC, _Awne.-- 525 Pelandale Mod ur., 290813 PHDNE/545-1185 PUB CONTRACTOR ADDRESS UCI PHONE I TYPE OF WELL/PUMP, 11 NEW WELL ❑ REPLACEMENT WELL ❑ MONRORfNG WELLr © OTHER D INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ © {1 YPE OF PUMPI Now 13R.pek H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p i ❑ OUT-0FBERVICE WELL © GEOPHYSICAL WELL I ❑ SOIL BORING g Cl DESTRUCTION: INTENOED USE TYPE OF CONSTRUCTION SPECIFICATION! A ❑ INIMSTRIAL ❑''yy�VOPEN BOTTOM DIA.OF WELL EXCAVATION_ `{J-`J II DIA.OF CONDUCTOR CASING p i 11OOMESTICIMVATE M04AVEL PACKMt;E TYPE OF CASINOISTEELIPVC S t e e I DIA.OF WELL CASING 1 211 O ❑ PUSUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION C R UIRIYOATIONIAG ❑OTHER GROUT SEAL INSTALLED sy H E G S OROUT BRAND NAME 13 MONITORING p MONITORING REVERSE 'R O T A R'P"OuT SEAL PUMPED, MY. [IN. CONCRETE PEDESTAL BY DRILLER;❑Y. OJ Ne S APFROX.DEPTH V LOCKWO CHESTER BOXISTOVE PIPE S PROPOSED CONSTRUCTTON/DIELLINO METHOD MUD ROTARY X X AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT t HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL,BE DONE IN ACCORDANCE MATH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CEITTIFtE9 THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SNALL NOT EMPLOY PERSONS SUSACT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR OUB•CONTRACTWO SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOR MAN'S COMPINOATTON LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOLARED INIWFCTION!AT 1.1408J423. COMPLETE DRAWING AT LOWER AREA PROVIDED. shpNod C One July 23 ) 1998, PLOT#LAN(brew to Seelel Scale 'to 1. 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,GPw'M OIMETI810N!AND MORIN DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 7, 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 PROPERTY, is - .1 OYF - ;... JUL 2.'7198 . :.. SAN JOAQUIN COUNTY ENVIRON EiVTAk 7H HEALTH V SIDN C � i I.1. y. .... .... .. ... : .. .. ....:... .. . ....... .... DEPMTMENT USE ONLY Applenlen Amooled By Date Grein Irnpeelbn BY Dns Pump ln.peetlen By Dote or Ontnrellen I—.salon ey Dole CemmerNe• -36T ' ACCOUNTINO ONLY: NOr FACT PE CODES FEE INFO AMOUNT RVATTED CHEC ICASH RECEIVED SV DATE PERMITIIERVICE REQUEST NUMSEIi INVOICE _ \ �� 707 w 1� 1 Pub Wealth Serv,-Enviro.173(1197)