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APPLICATION FOR WELL/PUMP PERM SAI ,OAOUIN COUNTY PUBLIC HEALTH SELACES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompintB In Triplieets) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANo/On INSTALL THE WOR( DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WILL It SAN JOAQUIN COUNTY DEVEL) -1 OP�� ,MJENT TITLE, CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. ^T JOB ADDRESS/OR APNS "r, R-TC1F \L.- que TlV& CITY ✓ I � -I�� PARCEL SIZE/APNI OWNER'BNAME PAc1F, c, l.G ( /• A5 Y! to CQS-Ff9 '-T' ADDRESS 4, 1y () � PQL r1C/ 0 , , 0V� PHONE / zuq - L/7fr - rJSoy CONTRACTOR AAJANC£ n GQQ � n ./ iMrwi A4 } I lA( � ADDRESS 7005 A/ )A/ OSQ0 W6 �, LIC/ ZZ- PHONE 9GSI 00. 4171 IPO IF 1 V p ANC!/F cNApo' aC SUB COMRACTOR @fl� ft�l VhI �P Dry ADDRESS ! • 9 �-D 3012 LIC/ IBSSf 7b lB PHONE F91Ila — 4JZ - bZbL -�INp2 t 99221 fro . NaII. GR TYPE OF WELLRHIMP: ❑ NEW WELL ❑ REPLACEMENT WELL yq MONITORING WELL S c 17-I 4V,i C� ,rL ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 0 J ❑ New ❑ Repair N.P. DEPTH PUMP suT ffl FIRST WATER LEVEL O (TYPE OF PUMP! ❑ OUT-OFSERVICE WELL ❑ GEOPHYSICAL WELL 1 ❑ 601E BORING B ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSQ A ❑ INDUSTRIAL ❑ OPENBOTTOM DIA. OF WELL EXCAVATION N"� ,CJDIA. OF CONDUCTOR CASING K) 14* 0 EI DOMEBTIC/PRIVATE AURAVEL PACK/BIZE r0LQ TYPE OF CASING/STEEL '\T /CJQy (� DIA. OF WELL CASINO dA� 0 ❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEM14 OF GROW SEAL N � O 179r.4- 1! 5 5�- SPECIFICATION c_ApOV )� 4D wT R IRRIGATION/AG ❑ OTHER GROW SEAL INSTALLED BY -IFAfeM\iL 'I IPL GROW BRAND NAME Vp Pa1GRn T\IPL -LL. E >irBB� MONITORING (' n 1, PPE GROUT SEAL PUMPED: EAtyw ❑ No CONCRETE PEDESTAL BV DRILLER: �Yw ❑ Na 5 APPROX. DEH '� So - r1f. +' S LOCKING CHESTER BOX/STOVE NU PTS PROPOSED CONSTRUCTIONImeLMNO METHOD; MU0110TARV AIR VOTARY AUGER CABLE OTHER I HE9EBY CERTIFY THAT I 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 JOAQUIN COUNTY, HOME OWNER OR LICENSED AGFWtS SIGNATURE CERTIFIER THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOR( FOR WHICH THIS PERMIT IB ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB COMPACTING SIGNATURE CERTIFIES THE FOLLOWING: ' 1 CERTIFY THAT IN THE PERFORMANCE OF THE Wow POR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS Of CALIFORNIA.- THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1100014063411, COMPLETE DRAWING AT LOWER AREA PROVIDED. RlaneeX TRIS S`F RFF lTD „ � n Gr S -7 Date l ! ' I 't'97 Plot PAN lorow to Some) 6oalw ' 10 1 . NAMES OF fiTREETB OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF BEWACE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN "blue OF ONE HUNDRED FIFTY FT. BTRUCTURES, INCLUDING COVERED AREAS SUCH AB PATIOS, DRIVFWAYB, AND WAMB, ON THE PROPERTY OR ADJOINING PHOPERTV. I . . . . : 1 DEPARTMENT USE ONLY Applleetlen Accepted By Dala / 3 , I Ares DV Grout Inspection BY Date Pump Inspection By Dua DwtnleRan InopeeBan By Date comrna„H: wewyw Aa ACCOUNTING ONLY: AIDE FACS PE CODES FEE INFO AMOUNT REMITTED CHECXSICASH RECEIVED BY DATE PERAUT/SETOnCE REQUEST NUMBER INVOICE A01 4 0 09 A6 Aofu 0 aM 0 ; I Pub. Health Sew. - Enviro. 173 (1/97)