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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 RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cempldt$ IB Trlplle$tal APPLICATION IS IIERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH pMSION, p /� JOB ADDRESSOR APNI /1 (.--. c(J <./L- l� aa: v C •� Ril J'j i,- ^�-�-S.J f CITY y� -�lJ "W PARCEL StZ OWNER'S NAME' � � t�.a2 '�S =UC ADDRESS 444 7 Vic✓ ^p ,� S 1 ,�. "4_c.4 �y'%.� 41-�i.-. .s... PHONE I_ 5 7-Nsc coNTRActoR Lr,t.nit 74 c /cy�� ,L AaxtEBdp(j ES... ,h,.,,j �4 ctt/t ucr PHONES 4V'`flL I .tt�i (t rlc�5f�5/E 1S:C� SUBCONTRACTOR =i)L ADORE 68 UC• J„Z/U IONONE TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 0 ❑ OTHER 11INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ❑Na—❑Rep alt H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O R YPE OF PUMPI 4c{j,— ❑ OVT-0E-SERVICE WELL ❑ GEOPHYSICAL WELL I Yw SOIL BORING c }� #3 g ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION$ A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMESTICMMVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PW DIA.OF WELL CASINO O ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 1,.,_._r SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY 4w--7 u,r+.-c GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yee ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Y« ❑No s APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE s PROPOSED CONSTRUCTIONX)MCLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE4E8Y CERTIFY THAT 1 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 JOAOUtN 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,191/ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SU"ONTRACTINO 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 WORIONAN'S COMPENSATION LAWS OF CALIFORNIA.' T APPLICANT MUST=ANCI FOR ALL REOUIRED INS►ECTIONS AT 120/►/gJ422. COMPLETE DRAWING AT LOWER AREA PROVIDED. t,/ //�� y819 dX 4 Tale /y/'jGC.f Li eu LDCI J% K.C•,. -a�`><L Date____L PLOT PLAN(Drew to Sodel Baala 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. $. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PFOPERTY,OWING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ]. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED $. LOCATION OF WELLS WIT-HfN RADIUS OF ONE HUNDRED FIFTY FT. BTRVCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WASK8. ON THE PROPERTY OR ADJOINMG PROPERTY. .. ___ E. ..;... i ..:... i .. ... .. .. .. .. " y� I /!L ' GPT- �ocnl�-c� e�. bt y. •4� cc-cc 1/055 s->yc t,4 c (/J�\I -_ `_ DEPMTM EHT USE ONLY ApPlloetlert Aeoepted BY_�-4 �7i/IM C YC Oele G Aw Grout Impactbn BY Z ( (70 Data pP� o Inapeetlert By Date Onatnretlen Impeetlon BY_ r i.S1w1�11/.L.� 1 G c i f "3 Data CommerHa: � � v' ACCOUNTING ONLY: AID# FAC/ PE CODES FEE INFO AMOUNT REMITTED CHECK#!CASH RECEIVED BY DATE FERMIT/SERVICE REQUEST NUMBER INVOICE 3S0 �ov �cj � 3/ St{-DoZz