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4PPLICATION FOR WELL/PUMP PERMh SAI<1r,rItAQUIN COUNTY PUBLIC HEALTH SEL,w, CES ENVIRONMENTAL HEALTH DIVISION 344 EAST WEBER AVENUE, STOCKTON, CA 95202 (249) 468-3420 NOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete IR TrlpReatel APPLICATION 19 HERE BY MADE TO THE SAN JOAOUfN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE. SE'JJ,CHq 11 '{APTER 9-1111.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. g JOB ADDRESSIOR APN# `� V d � 1 W Qjj '99., Illocil CITY PARCEL SIZEIAPNN 7-6I'Q 7-0' ONTIER•SNAMER'ASSij C. 4 t-lgria4 F. N,dSDbj... AQDTEBBZ43B95'`,r�/��ta5ti*1 84.11 Rigo4 953t&iowr 59.9- 4-Los CONTRACTOR S P e C tr_I,{M FAX.r 1 O r.Q f,1.J y ADDRESS "L3 16 5 y1r t_q 11.W L4 M rr ucp c��a a 6 0 PHONE N C i 7 1-Z �Y Stvc K f ON 1 CA 120$ RUB CONTRACTOR ADDRESS LIC, PHONE N TYPE OF WELUPUMP; 11NEW WELL 13REPLACEMENT WEu WELL ■ MowronwO WELL N I Of-amER IcAdAtAM ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Repel, H'P' DEPTH PUMP SET FT. FIRST WATER LEVEL O IT YPE OF PUMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL N 0 BOIL BORING .i Q 7�P�r t B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS nn r� A 13 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 8� hCF'S DIA.OF CONDUCTOR CASINO ' D ❑ DOME9TICIPRIVATE ❑GRAVEL PACK1812E TYPE OF CA91NG/STEELIPVC V rc- DIA.OF WELL CASINO -1" n c D ❑ PUBLK;IMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL I I - T Q_•C.}-1. SPECIFICATION 5th 4 0 p V L R ❑ IRRIGATIOWAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME N eg.'r. G-t m e K t E o MONITORING GROUT SEAL PUMPED: ❑Y. ON. CONCRETE PEDESTAL BY tMILLER:❑Yes []No 5 APPROX.DEPTH_ .7 D ` e e t LOCKING CHESTER BOXMTOVE PIPE S PROPOSED CONSTAUCTIONMOILUNO METHOD: MUD ROTARY AIR ROTARY AUGER x CABLE OTHER I HEI&BY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUM COUNTY, HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOnK FOR WHK:H THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATUM CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE RFORMANCE OF THE WORK FOR WHK:H THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN-0 COMPENSATION LAWS OF CAN ITor" PPU:7. UST CALL MUMS 1N ADVANCE FOR ALL REGUIRED TNSMTIr*AT t>0014+a�� ' T 9AAWINO AT LOWER DAREA PROVIDED.. /6 +�p TIfle ate PLOT PLAN Mow to Seater Seale G„'f 'to /]r`f" Jy JN!/ 1. NAMES OF STREETS OR S NEAREST TO OR BOUNCING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PnOIYISED P. OUTLINE OF THE PROPERTY,G1V*M OIMENBIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3, DMENSIONED OVyUNF.8 AND LOCATION OF ALL EXISTRM AND PROPOSED S. LOCATION OF WFUS WITMN RADUe OF ONE HUNDRED FIFTY F7. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WANKS. ON THE PROPERTY OR ADJOINING PROPERTY. PAYME .-MAY 61900 SltN jC)q 3UIN COLINZY EN1?fRp t IC:1 fEALTH sRVrcEs NTAL HEAlS(�t N!4►C . TYlS1DN DEPARTMENT Ve!ONLY i Appeeetlen Aeeaptd By bah Are. Goal kepeetbn by Oate PA Pv p Impentlen BY bate Doetntetlen Imp tan By �[y� ,[ bate S ell �S-7A-�l ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REIMITTFD CHECXNMASH RECEIVED BY DATE PERIA TISUMCE REQUEST NUNlaet INVOICE � 511 f Pub.Health Serv.-Enviro.173(1197)