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PLICATION FOR WEL.LIPUMP PERMiTj I SAN JOAQIJIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION f 304 EAST WEBER AVENUE,STOCKTON, CA 95202 (209)468-3420 NOW-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ' ICempleto fn TApRaetol APPLICATION IS HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERNIR TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN 'JOAQUIN COUNTY DEVELOPMENT TRUE,CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY P08UC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDREBa ,APN, RAR o!HG WAY 4 M E M I: 4 E[kj',I A M� CRY $To C�-rQ N _PARCEL 8T(EIAPNf OWNER'S NAME 5An TOALIVI(`lCATRdLIC cF-t4 tER`f A ... PC 66X':(13 . S 1�UCKTOR 95201 PHONE, 66"-•fib 20 ' CONTRACTOR +W <LL 1 l!y�A ADDRESS S I I V V iS U !q UCf��PHONE,• Q T I --I SUB CONTRACTOR � AOORE86 S I Lief PHONE T I S TYPE OF WELL/PUMP, ❑ NEW WELL ❑ REPLACEMENT WEIJ. .. '.�{ Z MONITORING wELL, Qh J ❑ OTHER ❑ IIBTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL, 1 J ❑New❑Remb H.P. DEPTH PUMP SET FT. - FIRST WATER LEVEL O {TWE OF PUMPI ,i, _ 13 OUT-OF-SERVICE WELL. 0 OEOPNYSICAL WELL f ❑ SOIL BORING B ❑DESTRVCTIONI INTENDER USE TYPE OF WELL 'i'CONSTRVCTUON&YECIFtCAT10N8 aI! ❑ INDUSTRIAL ❑OPEN BOTTOM S A OIAi!OIA (?FWELL EXCAVATION D T N G T� D .OF CONDUCTOR CASING_N A a SA ❑ DOMESTIC1PPIVATE ®GRAVEL PACKMtZE 3 N Vii.-.TYPES OF CABINO/STEEUPVC_ f GIA.OF WELL CASINO n2 IhIGK D ❑ PUBLICIMUNICIPAL ❑DRNEN ., DEPTH OF GROUT SEAL t3 V FEET p SPECIFICATION �r�V,U I U� � `1R ❑ IRRIGATIONIAO ❑OTHER QROUT''SEAL INSTALLED BY D R I t'�k R GROUT BRAND NAME NF-Ai 1 _G_ _ �_V tlrE 1 MONITORING : GRUUT REAL PUMPED:■Ya. ❑Ne CONCRETE PEDESTAL BY DISLLER:❑Ye. ON. ' S APPROX.DEPTH --0 F kE T i. LOCKING CHESTER BOXISTOVE PIPE 25 1 O7 V e p i F E s PROPOSED CONSTRUCTIONMRILUNO MTTHOO.' MUD ROTARY" AIN ROTARY AUGER X CABLE OTHER ' I HVMBY CERTIFY THAT 1 HAVE PREPARED THI8 APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND f%FGULATIONS OF THE BAN JOAQUIN COUNTY. HOMftWNER OR LICENSED J10EHT'B=NATURE CERTRnES THE FOIxOVNNG:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH i THIS PERMIT is ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WKMI OIAN' a COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIflES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PE 148 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORMA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE ROIL Ali 11Eomem INiPBCTIONS AT 120014Ses/2f. COMPLETE DRAWING AT LOWER AREA PROWDEO. Sta*�.d X Title C-f- i ENY, LI:NSJi.T�4N! 0.7. 31aI° � ji `l 3 S F-P H A M A G E, P: 5 056 PW T rLJUI iti:.y+to 6e.1.1 Be.1. •to ' I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE POOPERiY. 4. LOCATION OF HOUSE SEWAGE OISPOBAL SYSTEM OR PROPOSED '2. OUTUNE OF THE PnOPERIY.GIVING DIMENSIONS AND NORTH nw;:TION. EXPANSIOH OF SEWAGE DISPOSAL SYSTEMS. .3. DIMENSIONED OUTLINER AND LOCATION OF ALL EXISTING AND PHOPOBEO S. LOCATION OF WELLS NRTNIN gAOR18 OF ONE HUNDRED FIFTY FT. i1 BTRUCTUREB.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. ] E..E T A Gt i` 5 I.. .t P.L N.. :........ ... ...........:... i i DEPARTMENT USE ONLY AOPIkN1en Aeeepted Br ��" '••r \ it L��,P� Mrr i O'eut Impeellen By D.t.�' �' Pump ft""m"tIr I, i ne.rniee4en In�neetbn By " � ie Ce,nment. ACCOUNTINO ONLY: AID, :I. il FACS } PE CODES FEE INPO AMOU11IT REMITTED C Aa" RECEIVED BY DATE PomIrmERVICE REOUEST NUSMMEII INVOICE ' 37o I t go.1 - u D/Sry3 Pub.Health Serv.-Enviro.173(1/97 ii �