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PPLICATION FOR WELL/PUMP PERM" f $A QUIN COUNTY PUBLIC HEALTH SEt AS ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER;AVENUE, STOCKTON, CA 95202 (209) 468-3420 MDM"REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMrr TO ICONSTP CONSTRUCT lete 1it 1 A 11 101 INSTALL THE WOW DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WrTH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER$-1115.3 AND THE BTANDAR68 OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH DIVI810N. JOB ADDRESSMR APNI V 4 rt�a�v, �}• CITY Ii.� . .. .L_ A (•S,f ,^ PARCEL SIZE/APN#' OWNER'S NAME _ l�`�lL`.Vjy`� 1 `S'y.p� ADDRESSIV PHONE CONTRACTOR 51Nti\ l •CC NJl+7 L�Wy, t,(�t/pQ�y�l�j� �/p 4 \- tL..� ADDRESS 1 y (rVt� �.Z� 6 fv L cl sllo a 1 PHONE/ NT RUB CORACTOR ��` A N,\nu\w'V• v'A ADDRES8 3`C-1 5 ,{""i S Q�I� L,CP(E3 6�ps 6p 7� - PHO NE I�! Z-��"l� TYPE OF WELL/PUMP, ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONHORING WELL I �INBTALLATIOH 13 WELL SYSTEM REPAIR I© CROSS-CONNECT REPAIR ❑ OTHER © VAPOR EXTRACTION WELL/ � (TYPE DF PUMP) ❑NOW❑Repelr H.P, FIRST WATER LEVEL DEPTH PUMP SET FT. - A ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL/ ISOIL BORING 3 - 3o r 8 ❑DESTRUCTION., LI-NyTENDED USE TYPE OF W CONSTRUCTION SPfC1FICATIONBA r� U INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION (,,N �, DIA.OF CONDUCTOR CASING � 11DOMEST9CIPRiVATE ❑GRAVEL PACK181ZE TYPE OF CASIN0/6TEEtmvc N I blA.OF WELL CASING 11PUBLIC/MUNtCIPAL ElDRIVEN DEPTH OF GROUT SEAL__ � SPECIFICATION dI o 1e a ❑ IRRIOATION/AO OTHER GROUT SEAL INSTALLED BY �. GROUT BRAND NAME �F44- E i �MO DRTNG GROUT SEAL PUMPED: ❑Ye. Ne CONCRETE PEDESTAL BY DRILLER-(3 V. Ww. APPROX..D"T" LOCKING CHESTER BOX/STOVE PIPE pp I PROPOSED CONSTRUCTIONIDRILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER V/ SIJ\f' �` S 1 HERESY CERTIFY THAT 1 HAVE PREPARED THIS AP FUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND I REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'e SIGNATURE CERTIFIES THE FOLLOWMG:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR 6U"OHrRACTING SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT 1N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 IS8UED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUSSTT]C�Atl.24 HOURS 1N ADVANCE FOR ALL REGUlRED INSPECTIONS AT("01469.1422. COMPLETE DRAWING AT LOWER AREA PROVIDED. (] Stoned X�l'",J - i` `Y'YYWT�'!. - _�TItle Date_ 7 ...._ i PLOT PLAN(Mew to Bele!86.19 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 DIRECTKTN, EXPANSION OP SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION of ALL EX19TING AND PROPOSED S. LOCATION OF WELLS W"MN RADIUS OF ONE HUMORED FIFTY FT.,! STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY O JN_INO_P�iOPFRTv. _ I x � ry 4 a a C - FWI'w Y y 88 ff O�i O o O . w .k.._. Y DEPARTMENT USE ONLY�- - �_� ArMlleetlen Ae.Ptd BY— b.1/ MM l Orocrt not ! Pump 1mP.etlan SY Data " D-limtIon TMpertlen By Date CommerNs: f jl—" I ACCOUNTING ONLY: AID/ '�FACS ! 14 � PE CODES FEE TNFb AMOUNT REMITTED CHECXOMASH RECEIVED BY DATE PERMITISERMCE REQUEST SER INVOICE L ! k } . I Pub,Health Serv.-Enviro.173(1/97) f }4 n