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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete M TrlpOtattl APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIORU INSTALL THE WOR( DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-111115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY MOM HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSMM AM# Rbl� c� L.OwL/` .7/kc W/7'�t�" F f)0.-D CRY -pj'fDU�•V /W� 1 <� ` v�9c. jly,p113Al rub 1 — l -Dl OWNER'n NAME Gln ��1'T \J C/T-S L/JVY1 �T ADDRESS . D • ODIC : 6011q � A,l H7LV'IYYC'y''!J (Z,S- B�/Z. fjb%S CO✓1Su / / / J PHONE c TABAGT6Ra L�C. CiI \l /LINL• ADDRE6e3/GY HO/V Ck. -cgs �'� PHONEF /G. 63®, o3!tL� ry gl �•5 =�1 fn aJ �rvl� w�e.,if-i-(� ACcasm; 399 S/Ted 's Place Mw0E?3 96S PNONE ,7119- �'L•35 �/ —�anrL � 9s� s> TYPE OF WELUPUMP: ❑ NAYWELL ❑ "PLACEMEW WELL ❑ MONITORING WELLa ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CmsscONNECT REPAIR ❑ VAPOR EXTRACTION WELL F J ❑ Now ❑ Reactor H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O RYPE OF PUMPI M ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL A Itl SOIL BORING B ❑ DESTRUCTION: , INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS / Bl q ❑ INDUSTRIAL L3 OPEN BOTTOM DIA. OF WELL EXCAVATION /' DIA. OF CONDUCTOR CASING D ❑ DOMESTICNW VATE ❑ GRAVEL PACIKMIZE TYPE OF CASINGMTEELIPVC DIA. OF WELL CASING p ❑ PUSUCNUNICIPAL ❑ OmwN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑ OTHER GROUT SEAL INGTALLED BY GROUT BRAND NAME E ❑ MONITORING ) GROUT SEAL PUMPED: [I Yet ❑ No CONCNETEMOESTAIBYDRILLER: ❑ Y" [] NOO5 NO APPROX. DEPTH L- ' ' LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONtTTIUCTIONIDRLUNG METHOD: MIJD TARP AIR ROTARY AUGER CABLE I HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILL BE DONE N ACCORDANCE 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 WOR( FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAI NWA: COWMCTOR'S HIRING OR StS CUWRACTING SIGNATURE CERTIFIES THE FOLLOWING: • 1 CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF THIF MytT 6L1LWIN/1MANGE FOR ALL REQUIRES INiRC/ N�T COMPLETE DRAWING AT LOWER DAiRA PROVIDED. / J/�/l ,moi Y'Y' —�_"A-/A/ lL/g /KJ.' fGl=•4 ate ?/ 2-O/ � ^� PLOT PLAN Phew to Sestal Sealts • to� 1 . NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISMIAL SYSTEM OR POPOSED 2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS- ON THE PROPERTY OR ADJOINING PHOiEgfY. Jri. . 1� 5 r ; y f � C yid I . ILI 11 102Atic' _ - ( ) o prsP�/t/5t`/z, sus ys J P LsLAV. 3$ t'7h 1 ✓ L' Di ' cT ZL. //L� ( 71 _ o� rod: MEN L 2r DEPARTMENT USE ONLY ApPlleatlen Accepted ByDal a I y' L �` At" Oreut Impaction By ��L •' "` vote p Inspection By Dale DoetrtvHpn Lvpectlan By Date cemmm ACCOUNTING ONLY: AID/ FACP PE CODES FEE INFO AMOUNT REMITTED CHECE ASN RECEIVED BY DATE PREAITRERVICE REQUEST NUMBER INVOICE !> fit `"° 0 6 Pub Health SerV. - Enviro. 173 (1/97)