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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 NOR-REFUIJDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compl$($its TripRe$ts) APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1 1 15.3 AND THE STANDARDS OF SAN JOAOVIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESSIOR APNf I 1�i� !.t/, /^�.Js S t hy>! CITY '04 PARCEL PARCEL SIZE/AF7JI /}- OWNER-9 NAME L •.`LC .`; -- --1.-• 't . , yS4�'� �.•V�t-�Pj ia AOOfE89 J ' C- S• �., 3; ! PHONE CONTRACTOR L ,u n,ta.n I,, V .•2 !' 1 G v i• 'i.�=L AooREea. DI e.*,; J `Y Ls�t! cf__. &')7/"l' J/"�PH ONE f 9Cls AVB CONTMCTORtn:.t c :+.II:,{� l' �Tt-7!7 V•S ADDRESS � i!0 Lice .S/VJ7 PHONE I •�i.d TYPE OF WELLIPUMP. NEW ❑ REPLACEMENT WELL ❑ MONITORING WELL f�t ❑ OTHER gINS =PONT ❑ WELL SYSTEM REPAIR 11CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL f New❑Rp.Ir H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ITYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELLf ❑ SOIL BORING S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION /r DIA.OF CONDUCTOR CASINO �/}- 0 ❑ DOMESTIC/PRIVATE �I GRAv£L PACK/SIZE.t-,.) '�..J.X TYPE OF CASINO/STEEVPVC ' �r.j II �JL Yr�L DIA.OF WELL CASING �_ -/,�,�t� p ❑ PUBLIC/MUNICIPAL ❑DRIVEN -'-� DEPTH OF GROUT SEAL Z. F[�F SPECIFICATION 1 1 R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BV "TjLr,�.y t.,,t �vS 'C GROUT BIND NAME E MONITORING GROUT SEAL PUMPED:E,Yr'' e v CONCRETE PEDESTAL BY DRILLER:OYw ❑Ne S APPROX.DEPTH �•'S •f-LG }— LOCKING CHESTERSOX/STOVE PIPE i JG S PROPOSED CONBTRUCTION/ORILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER -- I HE4EBY CERTIFY THAT 1 HAVE PREPARED T14I6 APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S 61ONATURE CERTIFIES THE FOLLOWINOt'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT la ISSUED,191/ALL NOT EMPLOY PERSONA SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'9 HIRING OR RU"ONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CAUFORNIA.' T APPUCANT MV$T CALL 11 $ ADVANCE FOR ALL REQUIRED INSPECTION$AT 1"01400-34". COMPLETTE DRAWING AT LOWER AREA PROVIDED. /J Slaved X TP, Tltl.�,ec �G LCf%.5/ �`"•s �• Dots Lf✓ly/ PLOT PLAN ID• to So.lel Sod. 1. NAME@ OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,OIVINO DIMEMMONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOM BYSTEMS. 3. DIMENSIONED OUTLINE*AND LOCATION OF ALL EXISTfNO AND PROPOSED S. LOCATION OF WELLS WRHtN RADIO$OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS 9UCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. .... .... ..... DEPAATMEHT USE ONLY Appkstton Aoo.pted BY Dot. Grout Impeetlon BY O1M _Dae Rsnp InrPectlen BY —Dot.�n1 (``'/ D-t—len I-P-0-BY [).too _ Commtt..t.- ^- ACCOUNTING ONLY: AIDE FACE PE CODES FEE INFO AMOUNT REMITTED CHECK/JCASH RECEIVED BY DAT PERMIT/SERVICE REQUEST NUMBER INVOICE o , oo 5 o o Pub Health Serv.-Envirc.173(1/97)