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000� 9� APPLICATION FOR WELLIPUMP PERMIT �..SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICt:. ENVIRONMENTAL HEALTH DIVISION P,O, 13OX 388, SM EAST WEBER AVENUE, STOCKTON, CA 95201388 12091 400.3420 NDFUREFUMAABLE PERMIT EXPIRES I YEAR FRAM DATE ISSUED IComplea In TripReetd FILE COPY APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.111 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. 1 JOB ADDRE98A7R A/PNx/iZ��2A41E /z� � _Crrr 5-AoG`_--ro.A. _ _ _- PARCEL SIZE/APNO f OWNER'S NAME ` �� 6goe ADDRESS/2FZ Al- oew S/k ]ONE 3 f� CONTRACTOR / D. ,J s :Z"C-- IY gir J40 LOdl -uCPHONEx 15 —3'719/ SUB CONTRACTOR __../V�/4 .,. ..,.._ADDRESS- -__---_-. UC# PHONE# TYPE OF WELL/PUMP. ❑ NEW WELL © REPLACEMENT WELL ❑ MONITORING WELL x ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL x ,) ❑New❑Revel, H.P. DEPTH PUMP SEF FT. FIRST WATER LEVEL 0 rTYPE OE PUMPI ❑ OUT-OF-SERVRCE WELL ❑ OEOPHYSICAL WELL x SOIL BORING Q0T&//XfiGi9 L s ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION Kra DIA.OF CONDUCTOR CASING D ❑ DOMESTMIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEEL/PVC DIA.OF WELL CASWO 0 1. ❑ PUBUCfMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R J y ❑ IRRMATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME S 0)[' Gx,.s JE ❑ MONITORING r I GROUT SEAL PVMPED: ❑Ye. ❑He CONCRETE PEDESTAL BY DRILLER:❑Yee ©Ne S APPROX.DEPTH I.] �GIL p �• LOCKING CHESTER BOX/STOVE PIP£ g PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUtlER--!�00-_CABLE OTHER ' 1 1 HEgEBY CERTIFY THAT I HAVE 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 SIGNATURE CERTIFIES THE FOLLOWING;'1 CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT le ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES J THE FOLLOWINO; '1 CERTIFY THAT I�CALILIURIII MANCE OF THE WORK FOR WHICH THIS PERMIrT 10 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORRMAWS COMPENSATION LAWS Of M1` CAUFOR CANT MUST IN ADVANCE FOR ALL REQUIREDDIINNSPPE'CTION$AT 13001 490-S422. 90-5 22./�COMPME DRAWING AT LOWER AREA PROYI /D. '{ Signed X TIB�29LT,-opA 2=LZc f'��/�/ty ...�....D.te /V =! �1 _ rr! a PIOT KAN IDrrw.to Soelel goals i,�,-•le E'� 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,GIVING DIMENSIONS AND NORTH DIRECTION. -- EXPARMN OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION Of ALL EXISTING AND PROPOSED S, LOCATION OF WELLS WTrMN RADIUS OF ONE HU"OAEO FIFTY FT. ' STRUCTURES,INCLVDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. - ON THE PROPERTY OR ADJOINING PROPERTY. - ....... f7L f ifit /�e AT> fA i O I - i i I —inn 5:. A a , r i .r. x `rte >' r- I.N..r w ' DEPARTMENT D6E ONLY .,,UivlviENTAL HEA -I-H DIVISIpr Applicellon Aceepled BY bele Mae 101-1 Oroal ImpwL1cn By pate RsnP InePoellen 9y _ — --_ - Oe Irmtlen Impeellon 0Y Comment►: L ACCOUNTING ONLY: AID# FAC# F PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMITISERVICE REGUEST NUMBER INVOICE G p ,)� (.rJ l 3al 7 O35 93 Pub.Health Serv.-Enviro.173(3196) I