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I. A q APPLICATION FOR WELL/PUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE;STOCKTON, CA 95202 (209) 468-3420 U . NON•REFUNDABEE PERMIT EXPIRES 1 YEAR FROM RATE ISSUED omplate IS TrlpReatal APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDf0R INSTALL THE WON(DESCRIBED.THIS APPLICATION IB MADE IN COMPUANCE W"II SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC IIEALTH SERVICEB,ENVIRONMENTAL HEALTH OMSION. JOB ADDRESM111 APHI' r'l 4,:5for Cryy [ PARCEL SIZEIAPNN ,( i OWNER'S NAME 0 1 I IJ' ADDRE,s9 1z 10 b / reL /� ST PNONE g COHrRAc76R C G [, ADDRESS 3 f28 (r1Ylh] rQjkllle �l�j,c# t 2. PHONE- �G&-9156 SUBCONTRACTOR � 1I L'A h S�Dc C/OMiIS T 61226$PONE 04)yd5-8712 TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL il' IJFONRORING WELL/ ❑ OTHER ❑ INSTALLATION © WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑Now❑Rep k H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p (TYPE OF P'UMPI ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL t ❑ SOIL BORING g J r y�f�STRUCTION: / p INIFNDE026—IE TYPE OF CONSTRUCTION 13 INDUSTRIAL OPEN BOtttlM DIA.OF WELL EXCAVATIONTIONa SC- Q7Y4ch eel `lbIA.OF C'NDUCTOR CA81N�� ❑ DOME9TICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGMTEELIPVC- r] CJ DIA.OF WELL CASING . p ❑ MBUClMUMCIPAL ❑DRIVEN DEPTH OF GROUT SEAL'I• SPECIFICATION R ❑-IARIOATIONIAG ❑OTHER GROUT SEAL INSTALLED,BY GROUT BRAND NAME E ❑ MMTORING GROUT BEAL PIMPED: ❑YEN [IN. CONCRETE PEDESTAL SY DRIL]JER:❑Ye. [IN. S APPMXx OTMK LOCKING CHESTER SOXISTOVE PPE S PROPOSED CONSTRUOTIONIDOWNG METHOD: MUD ROTARY AIR ROTARY AUOER__.,A� ^CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPAREO THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AHO RULES AN REGULATIONS OF THE SAN JOAGUN COUNTY. HOME OWNER OR LICENSED AOENT'G SIGNATURE CERTIFIES THE POLLOWIM.--1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH i THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORMA.' CONTRACTOR'S I-MNG OR SUBCONTRACTING SIGNATURE CERTIFIES f THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOMMAN'S COMPENSATION LAWS OF CALPFOIWIA.' THE A"CANT MUST CALL 24 HOURS RI ADVANCE FOR ALL REOUIIED INSPECTIONS At 122091/b-M2=, COMPLETE ORA'V111 AT LOV41 AREA PROVIDED. Stoned X T$n. _ �_� T------ EL<<A74)15 / Date PLOT PLAN Mra to Sade$Sae$. `to 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY..yam, ,Ij .,, _„„,� 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED ,I 2. OUTLINE OF THE PROPERTY,GIVING DMENSION9 AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS.' J. DIMENSIONED Ot"tJNES AND LOCATION OF ALL EXISTMO AND PROPOSED S. LOCATION OF WELLS WITHIN RADMS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. r~ L ..,. E E DEPARTMENT USE ONLY - .l ` �l - Applketlon Aaeoptod By L_[tl�l r. lA I AA t'l�f� - Det.--L4 1, � Ater . Omit knpmtkn By Dots FLmp 1mPeatlon By ONe f Ontntetkn Impootkn BY Dote Comment.: l ACCOUNTING ONLY: AND/ .Y FACT' i PE CODES TEE INFO AMOVNT REMITTED q CHECKOWAsH RECEIVED BY li DATE PERMITISOMCE REQUEST NUM191 INVOICE Pub.Health Serv.-Enviro.173{1/97} i!. !