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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 NON"AEFUNDARLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComp4t7 In Trfpf est71 APPLICATION IS HEPE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED, THIS API'-'CATION IS MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1 115.3 AND T11E STANDARDS CF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIPONMENTAL HEALTH DIVISION. 1—W�. JOB ADDRESS/OR APNI 1't l 1y ,`T hl4 N IiI.L CITY I A ('i Cr 'ARCEL SIZEJAPN/ L 14 'c;—I OWNER'S NAME ADORESS I �'t n� Y /�r�, r r,/ L /�' PHONE CONTRACTOR `I I� l_ v A� ADOPESS - ��=ti •P 1 UCf PHONE L 1 t SUB CONTRACTOR V Iyt/ ADORESB UCl - l PONE! a=te 1 y TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL &j MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J ❑N•-❑Roo.11 H.P DEPTH PUMP SET FT. FIRST WATER LEVEL O [TYPE OF PUMP) ❑ OUTOF"BERVK:E WELL ❑ OEOPIVSICAI_WELL l ❑ SOLI BOTgNG B o£srRvcTloN: C�ti G 7 S 'K'r �� : G { r!� •( L — Z L I ! C/ -5 1i = C ti ! L,L. S /i G F-4 C — r INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O ❑ DOMESTICIPRIVATF ❑GRAVEL PACX/SIZE TYPE OF CASING/STFELIPVC DIA,OF WELL CASINO O ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROAT SEAL SPECIFICATION R ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PIMPED: ❑Ys ❑Ne CONCRETE PEOESTAL SY DRILLER!❑Yw CIN. S APPROX.DEPTH Z 1 CD��5 LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE 'OTHER I HE-IEBY CERTIFY THAT 1 HAVE r'REPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS.AND RULES AND PEGULATIONS OF THE SAN JOAOUII COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SU"OHTRACTtNG SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT M TINE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'?COMP-ENSAT10N LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED wIMSPVCTIONS AT IM AOt-3423. COMPETE DRAWING AT LOWER AREA PROVIDED. IM / J 1" SIt •d X TIN• PLOT PIAN 101—to 9e•1.1 Bo•1• 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR POPOSED 2. OUTLINE OF THE PROPERTY,G1V1No DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTI/O AND PROPOSED S. LOCATION OF WELLS VAT74M RADIUS OF ONE 14 UNDFMD FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOPM40 PROPERTY. DEPARTMENT USE ONLY ej APPIIe•tlon Aeertod BY 1� OH• 0— Pum•Imoeotl—BY Grout Imoeetlel•BY O•ta 01.•uvetlen In•nectlon Sr ,j, Commw.t•� '1 f'�� /Li l� wt r AID/ FACT PE CODES FEE INFO AMOUNT REMITTED CHEOVOtCASH RECEIVED BY DATE PgiBMITIl EAV10E REO VEST N1M lBER INVOICE rCC Puc Health Serv.--nviro. '73,1/97)