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APPLICATION FOR WELL/PUMP PERF SA OAOUIN COUNTY PUBLIC HEALTH SE, 110ES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WOW DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITTLE,CHAPTER 9-11115..3 ANNVD(/jHE�8-IANDAP09 OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. AP JOB ADDRESS/OR AI Q,( / I /^ • • '='F/ CITY M •"-.r(5:6,4— PARCEL SIZE/APNI OWNER'S NAME M I K((��C/ y�6� 1 AIIN N I ADDRESS INp&t,II;- W�LA SC ik<-,M A"I PHONE I f32/s -:3Z45 C CONTRACTOR C�K6�1�7 L/I`Ilfi.l Na., ADDRESS I J0'�U�]YJ F✓ 1 rLB:46 �A_G PHONE F(510)3iN5-/f Lc NSU AfY' ��/ L -4 N Gt ChwryUM&rQVk17DN MENTPd �+M•, 1NG ADDRESS Il-F'T�LE�7�,51�. �/�JLH UC{D, PHONE /�F) TYPE OF WELLPUMP: I!D NEW WELLS Co)❑REPLACEMENT WELL )4MONITORING WELL 1 FII W-1 A{I 'e❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROS&CONNECT REPAIR wee' ❑VAPOR EXTRACTION WELL E J ❑N-13 RayIr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMPI ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL* ❑ SOIL BORING @ ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS j A ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 8 DIA.OF CONDUCTOR CASING N 4- D ❑DOMESTICIMVATE GRAVEL PACK/SIZE TYPE OF CASING/STEELPVCG DIA.OF WELL CASING )�i)-� j/ Tj[' D ❑PUBLIO ( /MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL {E SPECIFICATION .NYI J ( VG @ ElL�?- IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY "G)Z GROUT BRAND NAME -NI E MONITORING '-19' GROUT SEAL PUMPED:❑Yr [IN. CONCRETE PEDESTAL SY DRILLE10— LIN. S APPROX.DEPTH A OCKINO CHESTER BOX STOVE-PE S PRO, FALL,CrOM{IAVCT10NfDISWNG METHOD:MUD ROTARV AIR ROTARY AUGER_ CABLE OTHER " 'PVGLL CD(V S;g j'�y�/ AF P-1r 17E] PF-flniGD LUV '7'N-E- l-"D 1 HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDA CE VATH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY T AT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' T A,."._ /MLI N 2�HOURS IN ADVANCE FOR ALLREGURED HHIPFCTON{AT 1I.-I�YJ{Ia,COMPLETE DRAWING AT LOWER AREA T'POVIDED. 6lw,w x "'"'^OT F_L�AN�w.w to ea.I.l so.G ^ '�`l•It 1.NAMES OF STREETS OR ROADS NEAREST TO OR VllluwrTllc PROPERTY. 1,LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED PROPERTY, Z.OUTLINE OF THE GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. O.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED a.LOCATION OF WELLS WIFTY WITHIN RADIUS OF ONE HUNDRED FFT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALXS, ON THE PROPERTY OR ADJOINING PROPERTY. APplDEPARTMENT USE ONLY kNbn Aoo•Pt•d By yN�(I•Y-W;n D•t• I�i�. � Ar•• OroUl tnevntlon By D•t• P—P INP•at100 DY D•b O:wtnnU•n Imn•n11en By Da. Comment•: ACCOUNTING ONLY: AID/ FAC/ R CODES FEE INFO AMOUNT REMITTED CHECK#/CAIH RECEIVED BY DATE PIRWIT/SERVICE REQUEST NUMBER INVOICE D Pub.Health Serv.-Enviro.173(1/97)