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APPLICATION FOR WELL/PUMP PES T SAN JOAQUIN COUNTY PUBLIC HEALTH S-RVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplknto) APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WrTH SAN JOAQUIN COUNTY DEVELOPMF.NT TITLE.CCNAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ( JOB ADDRESS/OR APN# I 1 / 2-/ 1 S-44 7-b " PARCEL SIZE 3 25 OWNER'S NAME L .` p �"eSj CLh . A qONEE 15903S,,j PHONE07-dZ��L� 77CONTRACTOR/ -L 94'— ADORE 89200'"�IE -y4etCPU #o:f-57r6/ SUS CONTRACTOR ADDnESB LIC# PHONE# TYPE OF WELLJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ,/ (TYPE OF PVMPI ❑New 1:1A.P.1t H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT-OF-SERVICE WELL ❑ OEOPIIYSICAL WELL# ❑ SOIL BORING S QDESTRUCTMN: Vy 1 `-"'"•�- Cc:rvL ,.-,-� .-n 2 71- Dft-D INTENDED USE TYPE OF WELL CONSTRVCTION SPECIFICATIONS 2 A ❑ INDUSTRIAL �y.G�❑�OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D S ElL DOMESTIC/PRIVATE AVEL PACK/SIZE TYPE OF CASING/ EF VC A-^t:A V DIA.OF WELL CASING ` D 06 ❑ LICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL \- SPECIFICATION_ v q IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY_'37:lf i aer- GROUT BRAND NAME 5 tip-Q- E ❑ MONITORING \\11 e! GROUT SEAL PUMPED:�rs 11 No CONCRETE PEDESTAL BV DRILLER:❑Yw [IN. S APPROX.DEPTH IN LOCKING CHESTER BOX/STOVE PIPE S S PROPOSED CONSTRUCTION/DN LUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND ryv��l REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TILS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES C THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,* Tt(-AJ`PI,J.CANT/M//U�ST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSIPSC�,TION4 AT 1220*11 4409,3422. COMPLETE DRAWING AT LOWER AREA PROVVI/'D/E/QJf 1\m` 810—A X L/��N,li'4t..._kwbr Tltls 6v"�(��) J / D.ts / L 'S/L� PLOT PLAN 1D,—to Boelel Ro.ls 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SFWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NOnTH DInECTION. EXPANSION OF SEWAGE 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 On ADJOINING PROPERTY. /1 •/' V. .. ... ... ... .. n DEPMTMENT USE ONLY 7 n APP11WIen Aeeeeted By_ ' ✓\ v A, �Z-- D.t. 0-4 I—P-sloes BY D.te P—P fmPeetlen By O.le ' 01»1-11on I.�..�Pejrtbn By C / q GL ACCOUNTING ONLY; AID# FACT PE CODES FEE INFO AMOUNT REMITTED CHECK#/CAeH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE z5 hD 5 Pub.Health Serv.-Enviro.173(1/97)