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APPLICATION FOR WELL/PUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICempwN In T►IpRoathl APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.TIIIS APPLICATION 18 MADE IN COMPLIANCE Wr7H SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE[STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEA`L_TH1 SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORE SS/OR APN, i 71,; ,[r�rT�l rf - j-T l'-(X:/ CITYI VG K-(l.�'v I pp PARCEL S12FJAPN, OWNER'S NAME.04 ✓I - V6? h ka ADDRESS Et", 1,-4" ADDRE � 4G uccoNTRAcroR UNteC �L41 �i / Uy PUB CONTRACTOR_.� ?n/ �}I.yI .�VIL ADDRESS F'U X51 !%iG "14/G��I' UCI TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONfTORINO WELL, ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL, J ❑New❑Papal, H.P, DEPTH PUMP SET FT. FIRST WATER LEVEL O IT YPE OF PUMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL, SOIL BORING S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONStt A y ❑ INDUSTRIAL ❑OPEN noTTOM DIA.OF WELL EXCAVATION 1 I L] DIA.OF CONDUCTOR CASINO 0 ❑ DOMESTICR9VVATE ❑GRAVEL PACK/SIZE TYPE OF CA91NG/9TEEL/PVC P7- DIA.OF WELL CASINO A//,' O 11PUBLIC/MUNICIPAL �❑yy DIOVEN 1 DEPTH OF GROUT SEAL / 2LT. SPECIFICATION --�- R ❑ IRRIGATION/AG EIOTHER NIA GROUT SEAL INSTALLED BY TIQ'of"e- GROUT BRAND NAME +" •Yt(d 4•*T'I+�Z' E ❑ MONITORING j GROUT SEAL PUMPED: ❑Yee gv- CONCRETE PEDESTAL BY DRILLER:❑Yee ;RN. S APPROX.DEPTH �"'l I LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONRMSLLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HE-EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,LAND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,181/ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALWORMA.- CONTRACTOR-8 HIRING OR SU"ONTRACTMO SIGNATURE CERTIFIES THE FOLLOWING: 'I ETAIFY THAT PN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORK]MAN'S COMPENSATION LAWS OF CALIFORNIA.' THE CANT MUST CALL 2+HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001 SM-7/4�_2r2. COMPLETE DRAWING AT LOWER AREA PROVIDED.ne 810d X W Tltle ��•D JI-Ii- LT e O 107L L Date :` �+J 3 —�— [ 7 PLOT PLAN(Ovew to Sahel Boole 'to 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,GIVn4G DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WTTHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINM PROPERTY. 1 /�✓� DEPARTMENT USE ONLY G Applleetten Aeeept -3 ed By ( `� t�� Dole I ( - 1-7 A— 0 i Grout Inepeatlen By vete P-0 Inepectlen By Date Drbuatten Imp—tion By Data C—ft'tet ACCOUNTING ONLY: AID, FACT PE CODES FEE INFO AMOUNT REMITTED ". /CAN" RECEIVED BY DATE PERMIT/SERVVICE REQUEST NUMBER INVOICE Pub Health Serv.-Enviro.173(1/97)