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SANMPPLICATION FOR WELL/PUMP PERM AOUIN COUNTY PUBLIC HEALTH SECES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 WOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Comptstt In Tripl"lests) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 JAND THE STANDARDS OF SAN JOAQUIN COUt'N-FY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION.I JOB ADDRESS/OR APNI7 J �/ V," Y `-o CITU ' t ��-�1' 1 PARCEL SIZEIAPN/ "yc.J —�� 11r^� l � OWNER'S NAME i r l 1,° 1�J r()I e L-�rr'LZ l;� ADDRESS ��0(-'7� yn�<%_e ' t I� 1�1�q�u.Y�' -f PHONE R / / j Z CONTRACTOR C� i-1`` ? ADrDREBB�. i 1t-�Ct- /k'— UC+T �`^'-C,.�;✓r�FHG L ' (u-0`3 8V8 CONTRACTOR S J `- r�llln I �L AbD�6F tt1 Sly f S�ZI ,1 ,C,)-}- UC#C57 ONE 'Z � ,-per/ TYPE OF WELL/PUMP: fil"NEW WELL ❑ REPLACEMENT WELL O MONITORING WELL E 'r1 ' ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 1 J ❑New❑P—eir H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) ❑ OUT-OF.SERVICE WELL ❑ GEOPHYSICAL WELL✓< ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A �) vl ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 75 1 �l DIA.OF CONDUCTOR CASING 0 ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINO/STEEL/I'VC rL �I'� "1DIA.OF WELL CASINO LI O ❑ PUBLIC/MUNICIPAL ❑-�/o IVEN DEPTH OF GROUT SEAL '�'! yam/ SPECIFICATION B ERIGATIONIAG LJ OTHER GROUT SEAL INSTALLED BY �/�t i t,y� GROAT BRAND NAME c E MONITORING //�� i GROUT SEAL PUMPED: 11 Y. ❑Ne CONCRETE PEDESTAL BY DRILLER: Ye. ON. S APPROX.DEPTH OLJ Y L LOCKING CHESTER BOX/STOVE PIPE �� S PROPOSED CONSTRIICTIOWDRILLINO METHOD: MUD ROTARY AIR ROTARY AUGER V CABLE OTHER 1 HEREBY CERTIFY THAT I 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'6 COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'8 HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- THE APPUC0,kNT MUST CALL 24 HOURS IN ADVANCE FOM ALL REQURED IN PECTIONS AT 1200)4663426. COMPLETE DRAWING AT LOWER AREA PROVIDED - SIC-A X Title Dae Y/ PLOT PIAN 1D,—to Sadel Se.le -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,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ]. DIMENSIONED f r�t11NF Allo LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ,\ )) CWO n(uAv N et ON THE PROPERTY OR ADJOINING PROPERTY. 1 r STRUCTURES, "'r - t a � o o it z z r , a m74 3, "rF Fi.a O O 3 ; ';�G M! Y°�C 4"�1 Vt A� .t,�'I.r� t � �. Aar � f F r r. !• CD O v aan5 o x U v C) O f N Ox.O'D O - ? 3.c4 N ID z O o F •' i t o O H , _ z m a! 1 1 {. 'ct h 1 (D -T DEPARTMENT USE ONLY Appticalon Aaoeotee By Das '� Arw Mout Inspection By Detd)�IZ (Pump ln.poetlon By L7/\ bmtn,rtlon In.pertl , y 2-/2" Dae r [7--l . cemmeuu: i - 2:d Z� 4J� C<2 AT 3,. ! /�RIfU — 25 ��K<-,1` �en/ _Oy6fZ t ' v 2.00c, I ; ACCOUNTING ONLY: AIDS FAC,1 SAN JO/V,, PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE PERMIT/tERMCE REQUEST NUMBER INVOICE W Pon:� dao Ja�67 Z Pub.Health Serv.-Enviro.173(1/97)