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1PPLICATION FOR WELL/PUMP PERMIT- SAN%wJAQUIN COUNTY PUBLIC HEALTH SEI ZES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (COMPMb in TrtpRents) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/on INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN/ Zd3 S • L%Ayq\w CITU_//C / �- C LN PARCEL SIZE/APNI OWNER'S NAMEA '633 7-3 'JWS _ PHONE#109 O COMPACTOR tTA Qomkz['4 toYyC'syk.- n ADDRESS JO© Q-4 UQ R\C-I V I"\V�JC/S�C�BCS!I RUB CONTRACTOR F57f9-7-Z2"57f9-7-Z2"PHONE A \SCS amdO\/�WVM� ADORE88 UC U30�0� '357 PHONE, ---- TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONRORINO WELL/ ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL RYPE OF PUMP) 11 Now 11Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p 11OUT-OF-SERVICEWELL ❑ GEOPHYSICAL WELL R AI-SOIL BORING Co '("C 3Q t e 11 DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING.. p ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO / p ❑ PUBLIC/MUNICIPAL ❑❑DRIVEN DEPTH OF GROUT SEAL ©` SPECIFICATION R ❑ IRRIGATION/AG 19/OTHER GROUT SEAL INSTALLED r BY GROUT BRAND NAME zt4 a : E A ❑ MONITORING GROUT SEAL PUMPED: E Yea ❑No CONCRETE PEDESTAL BY DRILLER:❑Y. ISN. S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE 41A 5 PROPOSED CON8TR\UCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN 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 PERrOnMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWINO: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'/THE APPLICANT MUST CALL 24"OURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT"14094422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Sfgned X r. _j(„(LM/1/l/L� _ �:1 � Title �✓�IA�V�.c,�i► M((~ 1= Date /013`q 7 PLOT PLAN(Drew to Seale)Boate 'to 1. NAMES OF STREETS OR ROADS NEARE8T TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE BEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND-LOCATION LOATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRIK --�_— 133a1S MOJNII - w — - w �a 1– .. — - @) w w Q 3N of Q Z om N Z H c Y Q Z W J LJ U Q 4. O J 0- J = N C) 0 Z W z Q Q 4J d U USLi o w d J ¢ I n a x ._ '= N = � In c Cm _ N HLL� a w z a =o z 1-- (A N Q z w Q 3 w M: o o O N N � N Ot Q Q U •� g 0 O m F o Y o � w 1 a � a Z 5 0 0 – � LJ04 0 R o o 0 Z 30N3J 3 v Z O W Q ONIaTnB 30V801S o r- z oaj m o w o W ),311v z z 0 LJ Ld J m o 1 VE049606 a3ewnN ' / DEPARTMENT USE ONLY Application Accepted By / r 1 Date _�Area Of WA Impeetbn By Date P—p Inapeetlon By w� Date Deatructlen Impaction BY Date CmN 13,,1 11-4 Dior kDW-Lel dc. l0'a'L Z- ACCOUNTING ONLY: AID# FACT PE CODES FEE INFO AMOUNT REMITTED CHECK/ICAs" RECEIVED BY DATE POWITISERVICE REQUEST NUMBER INVOICE Pub.Health Serv.-Enviro.173(1/97)