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w a v`f -3 APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION J 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICampla(a In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.TIPS APPLICATION IB MADE IN COMPLIANCE WR11 SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY/PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. /TO /V, A��h/S "R CITY �,U,�mr �_, PARCEL SIZE/APNI �( l� a 6 1 !! X17— 3 SY7 cti JOB AODRESS/OR APN/ 0 /� �� PHONE R 7 Z Z- Ss - �J ADORES B�7 n 7/r /�/ // 96 6 OWNER'S NAME�L„�,� IQ f� Q v ry / PHONE R /D l� �V �S / f �� y1 S AOtN7E88 + y /� 1 UC/ CONTRACTOR .!/c`/ Y UCR I'110NE R ADDftESB SVB CONTRACTOR ❑ MONITORING WELL R ❑ OTHER TYPE OF�LVPUM ❑ NEW WELL ❑ REPLACEMENT WELL J ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROS C O0PFTAIR FIRST WATER LEVEL❑ VAPOR EXTRACTION O S� � I,}LNe�v❑Ropelr II.P.�_ DEPTH PUMPMP SET 9ET ❑ SOIL BORING S (TYPE OF PUMP) // P }J ❑ DVT-or-%vlVICE WELL ❑ GEOPHYSICAL WELL R ❑DESTRUCTION: ," L(-�"� � � � A TYPf OF WELL CONI TRUCTION SPECIFICATIONS D INTENDED VfE DIA.OF CONDUCTOR CASING ❑OPEN BOTTOM DIA.OF WELL EXCAVATION �y i j D ❑ INDV 6TRIAL DIA.OF WELL CASINO C7 TYPE OF CASINO/6TEEL/PVC pOMESTICfT'RI VATE [I GRAVEL PACIIBIZE SPECIFICATION R PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL GROUT BRAND NAME E ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT SEAL PUMPED: E-1 Y— [IN. CONCRETE PEDESTAL BV DRILLER:Ely- ❑Ne 5 EI MONITORING S APPRO%.DEPTH. .z�5� LOCKING CHESTER BOX/STOVE PIPE G ROTARY_AUGER CABLE OTHER �1 PROPOSED CONSTRUCTIONMNLUNO METHOD: MUD ROTARY AIR ROSLJ 1 HEREBY CERTIFY THAT I HAVE PfiEPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULER AND REGULATIONS CERTIFY THE BAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES TNF FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH , 11115 PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONT MCTOR'8 HIRING OR SVBLONTMCTINO SIGNATURE CERTIFIER TIIE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CA 24 HOURS IN ADVANCE FOR ALL REQUIREDINS �TTQNS AT 12M1 4p COMiLEfE DRAWING AT LOWER AREA YID% �,,,,� �_ 0 � Tltle Blanee x Z• PLOT PIAN(brew to SCele)Soele 'to 4. LOCATION OF MUSE SEWAGE DISPOSAL SYSTEM OR PTtOP06ED i 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. OUTLINE OF THE PROPERTY,O1V*M DIMENSIONS AND NORTH DIRECTION. S. LOCATION OF WELLS WITMN RADIUS OF ONE HUNDRED FIFTY R. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EX19TMG AND PROPOSED ON THE PROPERTY OR ADJOINING PROPERTY. STRUCTURES,INCLUDING COVERED AREAS SUCH AB PATIOS,DRIVEWAYS,AND WALKS. ... _ _. Al ... i . ..E .... ... t r . 00 �y GN�,�.I 1 CI W EJ V s O ENT VSE ONLY ADDlloellen A—pld BY lila —im ` O.le Grout Irnpoctlon BY Det. PtmD IneDectlon B OHe D.ww.lon I—r-tlon BY Commdru: ACCOUNTING ONLY: AIDS FAC/ PE CODES FEE INFO AMOUNT REMITTED /CASH RECEIVED BY DATE P6MNF'Im'+Cf REQUfdf N,mgv, 0 /IyVOIL'I -13(1197)