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IT APPLICATION FOR WELL/PUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 952,02 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICamplata M TrIpDeata) APPLICATION 19 HERE BY MADE TO THE SAH JOAMN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WON(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEWLOPM•E7N�T7T�ITLLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL STEALTH OIVIBION, '2 { � JOB AODRESSMR APNi -5 /4- & ±j j Ti-fT��I�+Q '''t CITY �IZ+G/ PARCEL BIZEIAPN4a$ —03d 1,1 OWNER'S NAME � r S c.o J. Q� a.Mr/� C, v�,DOREBB If 3 - 1� - 14-- PHONE 11-1-L(1-4+17 AlavT CONTRACTOR AQUA -! 06 `— �/�/p"1��-[4I _ADDRESS 940 C JA ucI 4-d 70110 PHONE/5�� {� SUBCONTRACTOR (.,) f ADDRESS Ric ':r Ci' ucoc S 7.0 ONE I c� 37_9_2ff/5 PUS A� Pl�pllalp�e —- I� IPa _ TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL 13 MOHrTOWNO WELL 1 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL i 11New(3Repair H.P. DEPTH PUMP SET Fr, - FIRST WATER LEVEL G RYPE OF PUMPI �`r(/ - ❑ OUT-OF•SERVICE WELL ❑ GEOPHYSICAL WELL i JAI SOIL BORING a ❑DESTRUCTION: INTENDED USE TYPE OF WIELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO 0 ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKIIHZE TYPE OF CASINGISTEEUPVC TNA.OF WEit CASINO O ❑ PUaUCAMUNRCIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IMOATIONJAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E 11 MONITORING GROUT SEAL PUMPED, CJ Yee [IN. CONCRETE PEDESTAL BY DRILLER:❑Yea ❑Ne S APPROX.DEPTH LOCKING CHESTER BOXMtOVE RPE. S PROPOSED COMSTRUCT10N1DRILLINO METHOD, MUD ROTARY AIR ROTARY AUOER CABLE OT14ERno 6r✓ 111EREBY CERTIFY THAT 1 HAVE PIEPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE YOM SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND MOIMTIONS OF THE SAN JOAQUIN COUNTY, NOW OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•R CERTIFY THAT IN THE PEMORMANCE OF THE WOWS FOR WHICH TWO PERMIT IB 1 O,i SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES TME FOLL •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PEFIMT IB ISSUED,1 SMALL EMPLOY PERSONS SUBJECT TO WOMC MAN'S COMB FNBATION LAWS OF CALIFO THE tT110 T C HOURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS AT 120914"4b422. COMPLETE DRAWING AT LOWER AREA PROVIDED.p, Btmled TIIa_ 3j`' 1 1i ^JI /"'�� 'Ia' ...,..Data -3 _ 1- PLOT PLAN IOrew to Scale$Scale '[e 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATKN OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,OIVINO VOIAWS10N6 AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMB. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTMO AND PROPOSED S.LOCATION OF WELLS WA'TMN MINUS OF ONE HUNDRED FIFTY FT. StRUGTURlEB INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY, DEPARTMENT USE ONLY Application Acaapted By _ Date Marl` 7,A �- 0."Impaction BY Vale Pimp Impeetien BY Date Da*gtm len 6.epectlon BY Dole i ACCOUNTINQ ONLY: AID# FACT PE C0DEN FEE INFO AMOUNT REMITTED CH !CASH RECEIVED BY DATE PFAMITISOMCE REQUEST NLAMBERI INVOICE _ f Pub HeBIh Serv.-EnvirG.173(1/97)