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APPLICATION FOR WELL/PUMP PERM' SAA .JAOUIN COUNTY PUBLIC HEALTH SEk.(CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TripRests) APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC A/HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AODRESS/OR APPN/,E,/: P•��/ � '"AI`S CIN �(1"dl•�y ,/ A�r PARCEL SIZE/APH1 /n�� rim. OWNER'S NAME YAC"T 1/ posey ADDRESS SII M�I+N,./c-Iy(I/I.eA PHONE/r!N`J):7-/-y�/. Q[, /��''� F (NEZ Cbl CONTRACTOR �(KEa'L'I �!/r✓!�!/.'% AOD,�R/ESS/:/�. K�N'G /"r�•, L•/��jucl -/b' PHONE/l5(c)513 1751 G�rdS✓ stn eA-n40,2t,4 -W✓/120/�//L({i/ n:F � -),.&e.-ESS 1)�/�{ b5%T 5J. .SV7&c.'c, N CPHONEI(t7/�)g2t-3: TYPE OF WELLIPUMP: J�NEW WELL�0,t 11 REPLACEMENT WELL ❑MONITORING WELL• ❑OTHER r❑`INSTALLANTIOH' ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELLI J ❑N—❑P..?, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O RYPE OF PUMP) ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL* ❑ SOR BORING B []DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUC71ON SPECIFICATIONS (I A ❑INDUSTRIAL ❑OPEN BOTTOM yL. RDIA.OF WELL EXCAVATION / DIA.OF CONDUCTOR CASING NA- 0 ElDOMESTICR'NIVATE $kGRAVEL PACK/SIZE �T� TYPE OF CASING/STEELVC V G OIA-OF WELL CASING (( O ❑FI/BUCNAUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION �h ,tom �i�JG B ❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY DP—I LAE iZ GROUT BRAND NAME N/A- E MONITORING r T GROUT BEAL PUMPED: Vr ❑Ne CONCRETE PEDESTAL BY DRILLER Yw ON. 5 APPROX.DEPTH % "\ LOCKING CHESTER BO STOVE PIPE ,4Gl` 5 PRO ED CONSTRlK:T1ON/dSWNO METHOD:MUD ROTARY AIR ROTARY AUGER CABLE OTHER WALL CyNS;rzueTlt7n/ rD e,5.7 PNil✓ IN Mff nei.-D- 1 HE°IEBY 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 ANO REGL/IATIO'a OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERTORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.* TIME IN ADVANCE FOR ALL REQUIRED IIN/SSPEECCTIIOO�N@ AST/x.1200)11/4421.COMPLETE DRAWING AT LOWER AREA PROVIDED. � ^7 511-d X _ �jTln. /E/� PLOT PI-A r.w to Bo S�c.l. ClIz* L-AN 7.NAMES OF STILETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 1. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR MiGPOSED 2.OURINE OF THE P71OPERrY,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 PROPERTY. . _ ....... . ... .... I' DEPARTMENT USE ONLY Ap.V" 1bn Aetptd BY D.t. N `y V I_1 1 ffLL M Gleul I-,,.Iten BY S/ lw1/ O.t. Pump In.P.etlen DY D.l. D.alvllen 1—Pr--.I.n By D.t. C.,n,.m W ACCOVNTINO ONLY: AID/ FAC/ PE CODES FEE INFO AMOUNT REANTTED CHECKI/CASM RECEIVED SY GATE PERMIT/SERVICE REQUEST NUMSBR INVOICE Wk ALLp Pub.Health Serv.•Enviro.173(1/97)