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SA�PPLICATION FOR WELL/PUMP PERt� AOUIN COUNTY PUBLIC HEALTH S ICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Comploto In TtlplkGtol APFUCATION 1914E BY MADE TO THE SAN JOAOUN COUNTY FOR A PERMIT TO CONSTRUCT ANOMn INSTALL THE WOW DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TRUE.CHAPTER 8-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AODRESS,OR APNF 019-99W-07 19-99W-O7 CRY pc/E's-Mokrm PARCEL SIZEJAPNF OWNER'S NAME '1��-F`+v F/IF - KK ADDRESS �0 �Y PHONE# ouJIC, utBT.l ccNr/yAt;-pd.FC+s WL. ADDRESS 30 4L ST TS. If80 S.F 94lD7 PIONEF CONTRACTOR !Z /S SUBCOMRACTOR PPFn116(t.- 1/94LL4&)61 u/' ADDRESS P•O.BOX 903411 +05-*C{DS UCF 26$O�'$cc�swlsaPnnHONE F ` 10 TYPEOF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL F A OTHER�FCZOn�4s (2_270 ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLF J ❑New❑Re2el, H.P. DEPTH PUMP MT—FT. FIRST WATER LEVEL O RYOF PUMP) awlON❑ OUT SERVICE MLL ❑ GGEOPYSICALWELL F9LSOMO Z-ZSPA.6 7 B ❑DESTRUCTION: A# ST5ww-yk*4"TzA,A,4Fyf�yfm ii1- .s04EoffN"s A PIEZaM ' WHLL- 9E C M INTENDED USE TYPE OF WELL *CONSTRUCTION SPECIRCATIONE 8 C A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION .9 T/O DIA.OF CONDUCTOR CASING I N O ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEI/PVC Ne, DIA.OF WELL CASING O ❑ PIBUCRAUNICIPAL ❑OHIVEN DEPTH OF GROUT SEAL N 2o/ SPECIFICATION NH/S"AtQ.8, 21Ss41. R ❑ IMIGATION/AG OTHER (Q1�,2pp �� GROUT SEAL INSTALLED BYPI'�Glagjt OROUT BRAND NAME E MONITORING 22 BMW SEAL PRIMPED:F.Y. ❑Na CONCRETE PEDESTAL BY DRLLER:❑Yr ❑No S APPROX.DEPTH 9� LOCKING CHESTER SOXISTOVE FIFE C+4124"tx 60,0 S PROPOSER CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR VOTARY AUGER CABLE OTHER it FW A P&IN d OR NJ awt-' 'A' 1 HMAY CERTIFY THAT I HAVE PiEPAREO THIS APPLICATION AND THAT THE WORK WILL BE DONE VIN WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND, REGULATIONS Of THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IG ISSUED,I SHALL NO MPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTINGSIGNATURE CERTIFIES THE FOLLOWING: '1 RIFY Ti T 11 TINE PERFERMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISGUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA: T A AMT UGT 34/HOURS IN ADVANCE FOR ALL REOUIREO INSPECTIONS AT I201914004 422. COMPETE DRAWING AT LOWER AREA PROVIDED. Bl'm X TIG. PLOT PLAM 1D,Fw le Se Mal Seals 'le I. NAMES OF STREETS OR S NEAREST TO R BOUNUND THE PROTErtrv, t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM 00 PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NOWN DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OURINF.G AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WRHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. pLAASIE-- 5EEf—= AaT'TtEc r. o Ft6R.1r 1 Kr�Anl o W T415- son- sAW1 4KK A14V aelaLystS PL ...... �j DEPARTMENT USE ONLY