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APPLICATION FOR WELL/PUMP PERMIT ' SA*AOUIN COUNTY PUBLIC HEALTH SEES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 2- (209) 468-3420 NOM REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DII7E ISSUED (CompORIGINAL /`''� Mu In Trlplkall APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIN APPLICATION 16 MADE MWWN COMPLIANCE WITH SAN J 7 JOAQUIN COUNTY DEVELOPMENT T11 /LE�CHAPTER/9 l-11115.8 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH JOB ADDRESS/OR APNI l37°i' CITY J➢DC�S'YG✓I PARCEL StZUAMN .9e.�-�' (sbe bi) /vo0 PewGll St /2 Fio0r OWNER'S NAMEC/0 1Y c17' Rra ctChIIu) �L�e�INC-FrYC.FE .ROfW ADDRESS J u�0� 1 /IIS C,4 SJV609• /*"Z� PHONES S/0'65-9 JPO CONTRACTOR ADDRESS UCI PHONER owe d SUN coNTRAcroR arru,9 TA,-Sl:�u rrv� ADOnesBMa/ �CF1 9YS63 tJCI ek<6VO7 PHoNERS/O'3/5-68 TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑Nev❑Rep.lr H.P. DEPTH PIMP SET—FT. FIRST WATER LEVEL O STYPE OF PIMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL R ® 6011 BORINGR ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS q A 11 INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION N '(iq C.J1PS DIA.OF CONDUCTOR CASING A//77 O ❑ DOMESTgR'RIVATE 11 GRAVEL PACKGVZE TYPE OF CA61NGRHEEVPVc A/IFJ // ,DIA.OF WELL CASING A/Aql // O 11PI8UC/MUHICIPAL ❑DRIVEN DEPTH OF GROUP SEAL -/'0/110/ C106p71-YI SPECIFICATION C A 74-- bPA)/LTYU/re R �1 ❑ IRRIGATION/AG ®OTHER GROUT SEAL INSTALLED BY QO AJL rae-><o/' GROUT BRAND NAME N11:2 E ❑ MONITORING145 ( GROUT SEAL PUMPED: ®Ys [IN. ❑ Ne CONCRETE PEDESTAL By DLLER❑Yr Ne ,VI)! S APPROX.DEPTH 15O LOCKING CHESTEn BOX/STOVE PPE A//Rl/ S IB PROPOSED CONSTRUCTION/ULLING METHOD: MUD ROTARY AIR NOTARY AUGE0. CABLE OTHER dE e ?US/W 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 JOAOUIN COUNTY. HOME OWNER OR LICENSED AOENT-S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 BIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTMCTOR'S HIRING OR SU"ONTRi SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN NE PERFORMANCE F THE WOR(FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' TF APPUC ETC 24 HOUIRS INA ANCE FOR ALL REQUIRED INSPECTIONS AT LHHR 4410 M22. COMPLETE DRAWING AT LOWER AREA FROM D�./� Bl.r-1% Till. Sl e- PrOIP•LT /'Ia NQq pr- D.te w PLOT PLAN IDI.w to Sed•I S.N. 'to I. NAMES OF STREETS OR ROADS NEA ST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENsq Ne AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. 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 AB PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING FAOPERTY. I :......... ........:... 0 DEPARTMENT USE ONLY P'�AV p�ME rppWp Appllc.tlan Acemted By Y�N[ N~1 D G'..Inep«Ileo By Dae wnv IrnP«nen ey D.t. D«m.euen Imo«Gen By D.t Q U V Cemn,enl.: 4V1l 14 f �/ [LCd FLAN JOAQUINFPO - UNIY (O C ENVIRONMENTAL HEALTH DIVISION ACCOUNTING ONLY: AIDS FACI PE CODES FEE INFO AMOUNT REMITTED CHECKI/CASH RECEIVED BY DATE PFAMIT/SERVICE REOMST NUMBER INVOICE ZRfl I 5 8 Pub.Health SEN.-EnvirG.173(1/97)