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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - c ENVIRONMENTAL HEALTH DIVISION J 9 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complab in Triplicate► APPLICATION IS 14ERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRII SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESSOR APN# f 1 N�' Llit C� L:.LJ,S e CITY • t� ,N •i/ l✓7 c"+./'1�^ tJp-C.. Ski c, PARCEL SI2El_sJG 2 OWNER'S NAME VCJ :Z?yc ADDRESS PHONE# G'��- X St:C. / 7c: c ac;,ii av t# I y; CONTRACTOR ('•_•.-�:,114t)l-y CI�scJSCf :s=yC ADDRESS— E_i-`v io,U,-_; i l°. LIC# A�PHONE 0 RVB CONTRACTOR p ,� p(�-.,,a �-iy•..I ADORE 88 �_.-jL t,•., CA 9 /[. uc#2L PHONE# 5'1f:i7� TYPE OF WELL/PVMP; �NEW WELL ❑ REPLACEMENT WELL MONITORING WELL/_ � ❑ OTHER 0 INSTALLATION ❑ WELL SYSTEM REPAIR ��❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# (TYPE OF PVMPI -/ ❑New 11Repalt H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOMDIA.OF WELL EXCAVATION /gyp; 7Ti l C JAJCLt] DIA.OF CONDUCTOR CASINO jj�h D 11 DOMESTIc rmVATE KGRAVEL PACK/SIZE ( a.C✓/ .YPE OF CASINO/STEEL/PVC YJV`, L I, 1 l DIA.OF WELL CASINO ,,,—T-fL ' 11 PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL R 'f'C'} (�.3 -�r<4 SPECIFICATION 8 ❑ IRROATION/AO It i I'.; GROUT SEAL INSTALLED BY /''yL�_t-� i S-t GROUT BRAND NAME �7� f XMONITORING GROUT SEAL PUMPED: ;9 Y. [IN. CONCRETE PEDESTAL BY DRILLER:M Yw�❑No S i APPROX.DEPTH rS iL� 7:s LOCKING CHESTER BOX/STOVE PIPE_ &4 S PROPOSED CONSTAUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AMER CABLE OTHER 1 HE'tEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAOLIIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF T14E WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN TME PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP'FHSATION LAWS OF CALIFORNIA.' T APPLICANT MUST CALL24 N ADVANCE FOR ALL REQUIRED INSMTIONS AT(2051 440J422. COMPLETE DRAWINO AT LOWER AREA PROVIDED. P BlSned x TItI. �m:N'c _! c�,t.-c.a:.i�:' :# Vote PLOT PLAN(Draw to SeNel S-1. 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,OIVMIO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE 04SPOGAL 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 APPlleatlen Aeoepted By Dat. O Ar.. Grout Inapoetlon By �X,- d,f,L� Dot-412t— et- a PL p Inepeetlon By Date DMlruetlen I—P-0—SY Oats cemmerNa: ACCOUNTING ONLY: AID# FACT PE CODES FEE INFO AMOUNT REMITTED CHECK#!CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE o •o� 3t 6o ti � o0 Pub Health Serv.-Enviro. 173(1/97)