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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 iB Tr1pReata1 APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. l JOB ADDRESS/OR APN# /j q� ,,t/, L r t y s-r /f✓L CITY f,�},LJkC.} PARCEL SIZE/APNIZ�'-24.,-2 OWNER'S NAME ©,l j ,1..l.4.�IeC_h e i=.a,1` ADDRESS ,.•t'±,,t-.jC CLs�- �L{_'S E'`, PHONE f L. S J X•3CL) CONTRACTOR /^n?=j Q t,i*--V USJi` _ 7-D)j� i<Lb! C ' k-.-p Sr lE i Y 9iS ` I C-�' TnJ ADDRESS CI �.J Ci J PHONE I \ !�, �u�' ,. ,. T / ZSR SUBCONTRACTOR -t -;(j„ ]�S' 'J .TAJ L_. ADDRESSt,- ('�- UCI ;1 j(�,> PHONE I �, r TYPE OF WELUPUMP: I NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# K4._a-A/C; ❑ OTHER INSTALLATION ❑ WELL SYSTEM REPAIR 13CR08S-CONNECT REPAU4 PAVJ q ❑ VAPOR EXTRACTION WELL I J Nsw❑Rep•Ir H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OLIT-0E-SERVICE WELL ❑ GEOPHYSICAL WELL Jr ❑ SOIL BORING g - ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS i A ❑ INDUSTRIAL ❑OPEN BOTTOM •(/J)DIA.OF WELL EXCAVATION (6 - I,l.i..h.1�,,,$`' DIA.OF CONDUCTOR CASINO c D ❑ DOMESTIC/PRIVATE J}pw-�,�GRAVEL PACK/SIZE ':L u' TYPE OF CASINO/STEEUPVC icy'[_ll- .Si R. '+Z� DIA.OF WELL CASINO (JAI Jt,{� p ❑ PUBIJC/MUNIMPAL U DRIVEN DEPTH OF GROUT SEAL__ J �tC:l" SPECIFICATION R ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY i rt.•tg11,.! �..:�C GROUT BRAND NAME T� �� E Y1 MONITORING 7 GROUT SEAL PUMPED:OY•• [IN. CONCRETE PEDESTAL BY DRILLER:IKY« 11 No S APPROX.DEPTH < LOCKING CHESTER BOX/STOVE PIPE_ S PROPOSED CONSTRUC TION/DRILLING METHOD: MUD ROTARY_ AIRROTARY OTARY AUGER CABLE OTHER 1 HE9EBY 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 JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTWO SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 NO AD,ANCE FOR ALL REQUIRED INSPECTIONS AT f2061468-S422. COMPLETE DRAWING AT LOWER AREA PROVIDED. e L / SRm+ee X ti Tltl•_ _ ,0,-�,f.•_I !YL:��S'.+'Sim ,� 2- D•t•__��/� PLOT PLAN BAsw to Se.10 So•1• 'to 1. NAMES OF STRREET8 OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PFOPOSED 2. OUTLINE OF THE PROPERTY,OPlNG 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. DEPARTMENT USE ONLY Application Accepted BY b•t• /yy amm Inmpeetle.By , l PT G' D•te %C / Pu-p Impeeven By l/ Date O.»w.11en I-peetlen By DW Comment.: ACCOUNTING ONLY: AID/ FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED By 0 TE, PERMIT/SERVICE REQUEST NUMBER INVOICE L o 0o A69 3 Puh Health Serv.-Enviro.173/1/971