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SAh"M\PPLICATION FOR WELL/PUMP PERM', �AQUIN COUNTY PUBLIC HEALTH SE' . ES ENVIRONMENTAL HEALTH DIVISION PAYMENT 304 EAST WEBER AVENUE, STOCKTON, CA 95202 ' } ' q (209) 468-3420 I" o W S � JUL 2 Z 1997 NOR-AEFURWLEIPERMIT ExPIRES t YEAR FROM DATE ISSUED [Complete In Triplieatt) APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOA A PERMIT to CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEV#R)7I TITLE,CHAPTER 9-1115.3 AND THE STANDA.ROB OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMRION. r'us ur u S JOB ADDR£sa LT � orvr CITY PAR L SIZErA°� OWNER'S NAME •.] ADDRESS '�7//,v" PHONE CONTRACTORN ,;_ ADDRESS UCIoh—z-az PHONE4� SUB CONTRACTOR ADDRESS LICE RHONE r TYPE OF WEUJMMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MOPNTORINo WELL R ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J (TYPE OF PVMPI LINew 1:1 Rep* H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p / ❑ OUT-OF-SERVICE WELL ❑ O£ORIYSICAL WELLeL-Y�'/ / BOIL BORING g ❑bEBTRUCTION; INTENDED US£ TYPE OF WELL COH14TRUC TION SPECIFICATION/ A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION___ I DHA.OF CONDUCTOR CASING p ❑ DOMESTICIPMVATE ❑GRAVEL PACK1StZE TYPE OF CASIN13I6TE£11PVC ••�- DIA.OF WELL CASINO p ❑ PUBLICYMUWCMAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAO ❑OTHER GROUT SEAL INSTALLED BY OROVY BRAND NAME C17 E OMTORiNG APPROX. GROUT SEAL PUMPED! [)Ys [IN. CONCRETE PEDESTAL BY RILLEM❑Yw Lr-YRa g OFPTH �✓ r � LOCKING CHESTER BOXISTOVE.RPE S, PROPOSED CONStRUCTIONIDINLUNG METHOD: MUD ROTARY AIR ROTARV AUGER CABLE OTHER i I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOFO(WILL BE DONE IN ACCORDANCE WITH BAN JOAOUtN COUNTY ORDINANCES,STATE LAWS,AND RULES AND � nEGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOEMT'B SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING 6IONATURE CEFITIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMR IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORXMAN't COMPtDYlATION LAWS OF CALIFORNIA.' i C T MVtT CALL 24 IN CE FOR ALL REQUIRED INH ONt AY{20f1 402-3422. COMPLETE DRAWING AT LOWER AREA PRO/V�IDED, Slerwd X Title Ofib PLOT PLAN IDeaw to Sedet Some 'to I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR Pr opo rEb 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMB. 3. DIMENStONEO OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK8. ON THE PROPERTY OA ADJOINING PROPERTY. :.....:............,.:.......1.... ....,.:......�.... .i..,..�....,.i....,.;....... .... .......:.....;.......i.....:-,...' I DEPARTMENT USE ONLY 4 Appllcaflon Aeeeeterf By v"' Det• v 92 Arw Grave tmpaeelen 8Y not 7 Puny tnevectlen BY Data 1 DMtrtrlien tmnection By Date Cemmaa.: b� ,� ayAL g2 y 6.-0 A-*- - ACCOUNTING ONLY; AID# 7 - FACE PE CODES FEE INFO AMOUNT REMITTED CMtg1! kASH RECEIVED BY ,Dk E POWITISEAVICE REQUEST NUFARER INVOICE �, r i67)f �� /1 /_ %' ' Oti uesNl.G... _Fnuirn 17"3 11 Ai71