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APPLICATION FOR WELL/'PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 915202 (209) 468-3420 r NOR REFU{RABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Camplatc In Tr(pRcala) APPLICATION 19 HERE BY MADE TO THE SAN JOAOUfN COUNTY FOR A PERMIT TO CONSTRUCT ANpMR INSTALL THE WORK DESCRIBED THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAM JOAOUIN COUNTY DEVELOPMENT TITLE CHAPTER 9 X1}11 S 3 AND THE STANDARDS OF SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION JOB ADDRE$S/OR APNE 7 f�I 'f„t,.1�k (.,.!+ ,,+ CITY I .rol c, PARCEL SIZEI/APN# y OWNER 8 NAME : ..:�4=Lr! ✓7�I 1 �'G �[ I L L � t J'„ r.�l J 7 % r' apORE9s r: fC , r 1�1 .►' t)Q� PHONE r O V.2 J 1 i �1 �., f CONTRACTOR s—h�i r i� i ] }�I(L I t�/{�. ADDRESS jf J LICA PHONE P f r is U f;7-1 t! j• ai I I '/ � iy'4 1✓ Al�A L ADORE88 11- 4 4 f LTC/ PHONE 0 -0-_71 OUR CONTRACTOR.�.�s � s J r, =f I, 1"1`L t -?\A 3 I3 1:4 TYPE OF WELUPUMP• ❑ NEW WELL ❑ REPL.AGEMENT WELL ❑ MONITORING WELL• ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VARDR E%TRACTION WELLl J ❑New❑Reoelr H P DEPTH PUMP SET FT FIRST WATER LEVEL 0 RYF+E OF PUMPF R / j ❑ OUT.OF-SEVIMCE WELL © GEOPHYSICAL WELL 0 L,.;1 SOD.RORIN0 ` � JB ❑DESTRUCTION INTENDED USE TYPE OF WELL CONBTRU¢710H_BPECIFICATIONS A ' ❑ INDUSTRIAL ❑OPEN BOTTOM DIA OF WELL EXCAVATION DIA OF CONDUCTOR CASINO D ❑ DOMFSTIC/PRIVATE 11 GRAVEL PACKMIZE TYPE OF CASINOfSTEEVPVC DIA OF WELL CASING D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY OROUT BRAND NAME E *01MONRTORUNG �� ,� GROUT SEAL PUMPED Ely.. ❑Ne CONCRETE PEDESTAL BY ORA.LER ❑Yee ❑No S FR APDX DEPTH 49" 2 SA, _ __ LOCKING CHESTER BOXISTOVE PIPE S PROPOSED CONGTRUCTION/DRILLINOM ETHOD MUD ROTARY —AIR ROTARY AUGER CABLE OTHEA.. _T I 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 JOAOUIN COUNTY HOME OWNER OR LICENSED AGENT 8 SIGNATURE CERTIPM8 THE FOLLOWING I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH ,MWITHIG PERMIT 18.tS8UED 1 9HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN a COIMPEN6AT10N LAWS OF CALIFORNIA- CONTRACTOR 8 HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES W-AE FOLWW( LOWING '1 CERTIFY THAT IN THE PERFORMANCE OF THE OFOR WHICH THIS PFRMIT IS ISSUFn I SHALL EMPLOY PERSONS SUBJECT TO WORIWAN a COMPENSATION LAWS OF UFORNIA,,-THE �}APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOLARED INGFECTIONa AT f2001 AJ90-Z427 COMPLETE DRAWING AT LOWER AREA PFOVI)pEO ,t Sla'-d X ! !� L!��% fll -^��" .... Title "�"1 i /7 4 c ✓ PLOT PLAN(Drew to Sade$Sade 'M Y 1 NAMES OF STREETS OR AOAO8 NEAREST TO OR SOUNDING THE PROPERTY 1 4 LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED OUTLINE OF THE PROPERTY GIVING DIMENSIONS AND NORTH DIRECTION EXPANSION OF SEWAGE DISPOSAL SYSTEMS 2 DIMENSIONED OUTLINFS AND LOCATION OF ALL EX19TING 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 _ I DEPARTMENT VSE ONLY