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LICATION FOR WELL/PUMP PERMIT SANJ, .QUIN COUNTY PUBLIC HEALTH SERV,. S ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 �v (209) 468-3420 NOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED lComple estel APPLICATION 18 HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ICTAND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8.1115,3 AND TIRE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH DIVISION, - JOB ADDRESSIOR APHI r af5 CITY C PARCEL BIZFIAPNI OWNER'S NAME I D ADDRESS PHONE P CONTRACTOR f,._� �� AODRE88 ICE WA-7 GOQ lir,7,dy77A- PHONED._ /-0`500 SUS CONTRACTOR ADDRESS ~ LIC/ PHONE/ TYPE OF WEA ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ IN8TALLA1ION ❑ WELL SYSTEM REPAIR ❑ µ CTIOSS-CONNECT REPAIR11 VAPOR EXTRACTION WELL I pYPE OF PUMP) • \`YYYYYY � - —z or Oelr H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL p ❑ OUT-OP-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING S ❑DESTRUCTION- MENDED VSE TYPE OF WELL CONSTRUCTION SPECIFICATION& A 0 INDUSTRIAL ©OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.Or CONDUCT On CASINO n ❑ DOMERIIC"IVATE ❑GRAVEL PACKISIZE TYPE OF CASINOIBTEELIPVC DIA.Or WELL CASINO d ❑ PUBLICAIUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R VOATIONtAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING / GROUT SEAL PUMPEO: ❑Yee [IN. CONCRETE PEbESTAt_BY DRILLER:❑Yr [:IN. S APPROX.DEPTH lo,20. LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONID ILUNO MET14001 MUD ROTARY AIR ROTARY —AUGER.. CABLE OTHER I HEREBY CERTIFY THAT I IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S BIONATURE CERTIFIES THE FOLLOWING;'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSON SUBJECT TO WORKMAN'@ COMPENSATION LAWS GF CALIFORNIA.- CONTRACTOR'@ HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF � CALIFORNIA.' T PPUCAN CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSP CTIONS)AT�12001499-3422, COMPLETE DRAWING AT LOWER AREA PROVIDED. �/s7 J1I Signed X Title � /w /Y C bete__ ! •J -/ 1 PLOT PLAN Ibrew to Scale]Sade •to 11 1. NAM OF STRtEET8 ROADS PARENT TO OR BOUNDING THE PROPERTY, 4, LOCATION OF HOUSE SEWAGE bISP'ONAL SYSTEM OR PROPOSED ]I 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, J .3. DIMENSIONED OUTLINES AND LOCATION Of ............ ,...- TION OF WELLS WITHIN ING PFI PE W. HUNDRED FIFTY 1'T. .. .-_-. ...:.. .... ..E PROPERTY OR ADJOINING PROPERTY. N PROPOSED S. LOCA 108.DRIVEWhY8.AND WALKS. ON 7H..,.. .p .... ..,.,-'-- - -.-.<.. .,........ .;.,...:, STRUCTURES.INCLUDING COVERED AREAS MUCH AS PAT : � - _ AJ sm - . 00.. PA)rRAE Nr ... Ara: �gca✓;I Pt18uC HEALTNSERVlcEs .. . rIVV1RpMMENT�L H : ALTH DI.V.RSION : .,.. ... : ..,..:. DEPARTMENT USE ONLY APPtlaettan Ace ad BY t Oele r � Aree - r1/ 6 av Oraul Impeatlen By .—.. Dete I'umP IrnpeaUen By Dwetnrctlen In.peatlon BY bele CemmerNe: ACCOUNTING ONLY: AIb;F PACO PE CODES FEE INFO AMOUNT REMITTED C ECK ASH RECEIVED BY DATE PERMITISFAVICE REQUEST NUMBER INVOICE bo 45Q 2�0 S 02-- Pub.Health 5erv.-EnvirD.173(1197)