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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICempM1e In T►IpReELE) APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 wANND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DrvISION, JOB ADDRESSOR APN# 3400 �eW TLS► ICoa81 CITY �-sTct jC� ON-1 f� e�� /�PAARCEL SI2E/APN# d / �J OWNER'S NAME A C p—I L' e i/1�b�t/r'ra._.`(lipN�♦T el) �p -�I ADORES. E,L0-V01. �8 3O 7,S•K K;0.-j i l M i PHONE/ 46(p—�J z�1/,� CONTRACTOR ADVAfJCrD 6jeClG"kl ftmIt'��,'/V�r l-,r/�c. ADDRESS 405 ry•WdSON W� LIC, PHONE.46/ —IW(o RUB CONTRACTOR l _/.t.i,A/ V ADDRESS UC/ PHONE TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORINO WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New Cl Repeb H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ry �� 0 OUT-OF-`SERVICE WELL ❑ GEOPHYSICAL WELL# SOIL BORING g !7DE/STRUCTION: ?0Y�tl& d ro rhw> I�oTrolr>, 10 Sur-44(L' ao�aeli. INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO 0 ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK1912E TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING 0 ❑ PUBLIC/MUMCIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION 9 ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E C GROUT SEAL PUMPED: ❑Y» Cl No CONCRETE PEDESTAL BY DRILLER:❑Y» ❑Ne S APPROX.DEPTH / tC LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONIDIIRUNO METHOD: MUD ROTARY AIR ROTARY _AUGER CABLE OTHER I HMBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M 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 IS ISSUED,191/ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMTT IS ISBVED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIIA"TT APPLICANT MUST CALL J24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(2001 400442!. COMPLETE DRAWING AT LOWER AREA PROVIDED. Blonee X �!:)1 i ��wFMr f� i TIN. M l=F Gtol o�iSt Ifk( � M1 a f� L Owe J v ►L01 PIAN IDteov to Seel.!SeelefIt_'to 30 ' 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,OIVINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OVTLMF.S AND LOCATION Of ALL EXIBTINO AND PROPOSED E. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTUREB,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINMG PROPERTY, .. SSSS., ` .; .i ..'... .:... SSSS..., ... .., ►'T . pIAJ 1. 6/� a L ............... :... DEPARTMENT USE ONLY ? Appileetlon Am pted By 1 ,Jrl�/�...0 ON. 7j Grout h»peetlen BY `iC�tilY L1.—— D.I. /J RmP Impoetlen By D.te Deeuuetlen I-peetlon By Cl 4 ��w/) Ow. — , Y 6 r/� L c e .c 'f'. !� ACCOVNTINO ONLY: AID# FAC/ PE CODES FEE INFO AMOUNT REMITTED CHECK#1CASH RECEIVED Sy DATE PERMIT/SERVICE REQUEST NUMBER INVOICE Pub Health Serv.-Enviro.173(1/97)