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►LICATION FOR WELLJPUMP PERM'' SA�QUIN COUNTY PUBLIC HEALTH SES v Y ENVIRONMENTAL HEALTH DIVISION _ r - 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IEompbor In TrlpReahl APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE 1N COMPLIANCE M711 SAN JOAQUIN COUNTY DEVELOPMENT TITLE,,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTYPUBUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESSlOR APR! N PARCEL 7-77 gT�pl/��► OWNER'S NAME S ADDRESS PHONE R 7 CONTRACTOR �L/�Y1 eSrt �f✓K9 V _. -- ADDRESS ��(Wyy--��'') UC• ��Q+�`. , p{{pZ�j��p .Ab7?6Q6' SUB CONTRACTORIQ-- �K��t�G � �rA�C'.'.�.._._.1SDDRE86 [,��LlCR:�+�/ PFIDHE L' TYPE OF WELLIPUM� w NEW WELL ❑ REPLACEMENT WELL 1 7 MOUMORINO WELL• OTHER ❑ INSTALLATION 1] WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL i J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMPI ❑ OUT-Or-SERvICE WELL ❑ GEOPHYSICAL WELLN L`T SOIL BORING 8 ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS FT QII n A ❑ INDUSTRIAL ,1]OPEN BOTTOM n DIA.OF WELL EXCAVATION ' U /�� DIA.OF CONDUCTOR CASING A)A- D ❑ DOMESTICMAIVATE 1.XORAVEL PACK!! TYPE OF CASINGMTEE DIA.OF WELL CASINO Z 8 ❑ PUBLIC/MUNtMPAL ❑DRIVEN DEPTH OF GROUT SEAL ZS�PECIFRCATION J� R TION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME /{aY I!J E MONITORING GROUT SEAL PIMPED: 0 Y. [IN. CONCRETE PEDESTAL BY DRILLER:❑Yw [IN. S APPROX.DEPTH 00 MY1hG LOCKING CHESTER SOXIBTOvE PIPE � S PROPOSED CONSTRMT1ONIMLUNG METHOD: MUD ROTARY AIA ROTARY AUGER � CABLE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THT9 APPLICATION AND THAT THE WORK WILL RE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT iB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORXMAN't COMPENSATION LAWS OF CALIFORNIA,- CONTRACTOR'S WRING OR SU"ONTRACTINO 61ONAIUPI CEFfrIFIES THE FOLLOWING: .1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'*COMPENSATION LAWS OF CALIFORNIA.- THE PPUCANT M ALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS At((20001 46841422. COMPLETE DRAWING AT LOWER AREA PROVIDED. "nod X —- Tltis� �(U! Date PLOT PLAN(Draw to Bade/Beale •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,OWING OIMENSKINS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLIWV AND LOCATION OF ALL EXISTMO AND PROPOSED E. 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. i .. ........... ........... .. .. . - DEPARTMENT USE ONLT Apploetlon F�eeeOted BY , �(- ..._ bels hr.pee lOn 'y �_ Dete '-i 4n2v Ion-By— Date Oe.eniellen Impaction BY es' r Dari b ACCOUNTING ONLY: AfDa► rACI PE CODES FEE INFO AMOUNT REMITTED CHECK#MASH REC6ED SY GATE PERMIT/gE rACE REOVIEEBT-NUMBER INVOICE Pub,Heafth 5erv.-Enviro.173(1/97)