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rATPLICATION FOR WELL/PUMP PERMIT SAN!, AQUIN COUNTY PUBLIC HEALTH SER.. ,ES ENVIRONMENTAL HEALTH DIVISION 304EAST WEBER AVENUE, STOCKTON, CA 95202. (209) 468-3420 NON•AEFUNDABEE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplat*III Troucatrl APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMR INSTALL THE WORK DESCRIBED.71118 APPLICATION IB MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115,.A3�AND THESTANDARDSOF SAN JOAQUIN COUNTY PUBUCC�HCALTII SERVICES,ENVIRONMENTAL HEALTH DIVISION. acre y� JOB ADDIIESSIOR APNI_l pp � Y�/k/ )GJL..J T�CITY I Pt�F ! ''} PARCEL SIZEIAPNI "v ac 1 eJ OWNER'S NAME L ADDRESS 10')0 Et t,L. (�' 1 ✓`+ . {L� PHONE I CONTRACTOR i ADDRESS I &� � L s Y/4-wo I1 `t f( G �`�'-' `1 �i �7 A/ 4 OUR CONTRACTOR t �L l 1 i'n 1 1��- AF7�S F I Ok S , 1� dDo r[� LTC/ 5/` P9ONE"0 r 777—'t100 TYPE OF WELIJPUMP: la!NEW WELL ❑ REPLACEMENT WELL L7 MONITORING WELL 8 M1'w r'3 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROB84CONNECT REPAIR ❑ VAPOR EXTRACTION WELL N J ❑New❑Rapelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O {tYPE OF PUMP) D OUT-OF-SERVICE WELL ❑ OEOPHYSICAL WELL N ❑ BOIL SORINO e ©bESTRUCTK)N: INTENbEb USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A r IL I ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION VIA.OF CONDUCTOR CARING D 0 DOMESTICIPRIVATE ❑GRAVEL PACKISIRE TYPE OF CASINOISTEE7 L �h u DFA-OF WELL CASINO LI D ❑ PUBLICIMUNICIPAL 111)OVEN DEPTH OF GROUT SEAL N•�' {i SPECIFICATION • ^•___,_._._ R ' ❑ Ij1R1OATIONIAO L`7 OTHER GROUT SEAL INSTALLED BY >^t 1 GROUT BRAND NAME F ,L-1-A�/MONITORINO �/f/ff11 �G GROUT SEAL PUMPED: Y. ❑❑YN. CONCRETE PEDESTAL BY DRILLER:BY. ❑Ne 5 APPROX.DEPTH 7S 0 Y 4- LOCKING CHESTER BOX/STOVE PIIPEE_ 5 PROPOSED CONSTRUCTIONIDPILLING METHOD: MUD ROTARY AIR ROTARY AUGER ✓ CABLE OTHER_ 1 Ht4tbY CERTIFY THAT 1 IIAVE PREPARED THIS APPLICATION AND THAT THE WOFK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AN REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWMER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHtCH T1118 PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIONATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPOMAT1ON LAWS OF CALIFORNIA.' THE APPLIC`1NT MUST CALL 2244'HHOOt R*IN ADVANCE FOR ALL REOUI EO 1 PEC TIONS AT 1120111 408�T22, COMPLETE DRAWING AT LOWER AREA PROVIDED Slar,eN X I ! Y/.f a"' Tw. .�L)s /�'/�[� l �L .__009 PLOT PLAN(D'*w to 606161 8-016 '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.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 7. DIMENSIONED Itrj INF D LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. .` STRUCTURES, ON 2 ON THE PROPERTY OR ADJOINING PROPERTY. c- 0 v - CJ 1+ jW O OO O O a v -,.4 - - m X C J ;Y-- t th2 'X' i• cl ss �3 11 S Q g _ , DEPARTMENT USE ONLY ' Application A-artitad By )) Dab Ar.. GIMA IMPabtIIM BY O.te/ In6P6attan By _ w.8yr J a`6 ry o T��r- Dn•vk,-tl6n Irnp"tt y <�/ O-to R fes- - - CammerNk: - utu 8 2000 ACCOLWTINO ONLY: AIDN FAC# SAN JOAGL;ity C(Iul'.-1 Puui Ir jj.F. I+t PE CODES FEE INFO AMOUNT REmITTEb CHECKNICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOIcE 100 110167 Pub.Health Serv,-EnYirG.173("T) s a t 1