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APPLICATION FOR WELL/PUMP PERMIT StWAOUIN COUNTY PUBLIC HEALTH SI9CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER .I,wQ (Complete in Triplicate) v!/ n �+r" J��o APPLICATION IF HERE BY MADE TO THE SAN JOAQUIN COUNTY FORA PERMIT TO CONSTRUCT ANDron INSTALL THE WORK DESCRIBED.Title APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT THIS CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH(SERVICES,ENVIRONMENFAL HLALTH DIVISION. �✓ror�f 'J.cO � we9t �0 p�� JOB ADDRESS/On APNI/37�/ /�iNCOII�7 I P nIT,N(' CITY �.n PARCEL 61ZEJAPNP Y JN W.enAl 3e# D Cle�A�+� �e L+IPCA..J! (sbel�s) /v Do AevcII St• /2 /--m r- owNE0'SNAMEgO {.II<J �[ -F 4 R ADDRESS Ue_P�In Ji/Ie. CR 9V6O$- /S'R2 P{ONE/ O.6J2-Sdap J CONTRACTOR ADDRESS me %ZONE# T FVB CONTRACTOR�/`�p0 � —S'><cc 1 � ADDnE88Ur�owG Id CF) uci (ix<6Y07 PHONEFS/0�3/5-58( TYPE OF WEL JPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ❑ PE OF PUMP( New❑Repslr N.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL 0 RY ❑ OU'OF SERVICE WELL ❑ GEOPHYSICAL WELL# ® SOIL BOOING R ❑DESTAUCTION: TENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION �pS DIA.OF CONDUCTOR CASINOp O LlC/PB DOMESTIIVATE 11 GRAVEL PACK/SIZE TYPE OF CASING/6TEEV C n/�fJ .t DIA.OF WELL CASINO / / D 11 PIBUCWUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL x'071011 rt7-' SPECIFICATION CrO%c&i7 - /LJFAilbuiXe- R ❑ IFF OATKIN/AG ®OTHER GROUT REAL INSTALLED BY CIOnJL raa-�Or GROUT BRAND NAME /IJ//a E ❑ MONITORING GROUT SEAL PIMPED: ®Yr (IN. CONCorTE PEDESTAL BY GRILLER:❑Vw ❑Ne A/iA S APPROX.DEPTH— So LOCKING CHESTED BOX/STOVE PPE A/I)9. // s p PROPOSED CONAUCTIONA RILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER OHI, i ?uSll 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APP)CATION AND THAT THE WOM WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNry OMINANCEB.STATE UWe,AND RULE8 AND MGU1JITIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIER THE FOLLOWING!'t CERTIFY THAT IN THE PERFORMANCE OFTHE WOPC FOR WHICH THIS PERMIT IB ISSUED,I BIHALL NOT EMPLOY PERSON8 SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CAUFOIWIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIER THE FOLLOWING: -I CERTIFY THAT 1 TIRE PERFCAMNCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- Tlfr P 1pAN.F MVS ALL 24 M 1lJ/IDVANCE FOR ALL REQUIRED IINSPECTIO^NNS AT 12WI 40111 122. COMPETE DRAWING AT LOWER AMA PK ID/ED-. Bl.—I X IyyFF''AA,,IIAAII M��\�LAA//llll Ail/J�y(1 (I Ir Tllle Si le- PrOlfe-1 / a/ 4Fq r- D.I. �..1 1{ Lei yj POT PUN Iw.w Ie Se.Iel Bele to I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. S. LOCATION OF HOUSE SEWAGE DIBFOBAL BYBTEM On FIIOIOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIBTOBAL 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 AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. MAR-0 1998 DEPARTMENT USE ONLY APPncumn AeeePl.d Br 7� / SAry�Of'Lg1NN CUUN( �� D.le ✓� 181 ALTH SE VICES O,eU Impecllen By O.I. P.nP Imp«Gen BY D.I. De.Inlnnen In.n�Ilen Br D.Ie Demmp,l.: C.,EZ— . �c �/ 3(0c) U) ACCOUNTING ONLY: AID/ FAC# PE CODES FEE INFO AMOUNT REMITTED CHECKNICASN RECEIVED BY DATE PERMITISLBVICE REQUEST NUMBER INVOICE 2-10( 33`J2 z U. D Pub.Health SEN.-Enviro. 173(1/97)