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��_ �XPPLICATION FOR WELL/PUMP PERM' SAf%"&OUIN COUNTY PUBLIC HEALTH SE�:ES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NOW-REFUNDABLE PEAMIT EXPIRES I YEAR FROM DATE ISSUED {Complete In TrIlpReet41 APPLICATION IS HERE BY?,LADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDJOn IHBtAIL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPUANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115,3 AND THE STANDARDS OF SAN JOAOVIN COUNTY PPU13U�C HEALTH SERVICES.ENVIRONMENTAL HEALTH OMMN. JOB ADDRE88JOR APNILf 1 C.�rS T �J�4 _CITY //�P�TG �] PARCEL SIZEJAPN/ e^ 'O��/ OWNER'S NAME 4 f(P©ny y 1�� - ADDRESS--7?pr^ c:k lJ�) ] PHONE R �45� CONTRACvcn—Al-VAYVP ..C�F�a t o -_ _ADDRESS I ViJ AJ t V if V UCE �Y . /SNE/ df&7 /M6 SUB CONTRACTOR ADDRESS tics PHONE I TYPE OF WEL,LJPUMP; ® NEW WELL ❑ REPLACEMENT WELL ❑ MONFrortwa WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRO99-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I YPE OF Pl1MPf ElNew❑Repair H.P. DEPTH PUMP RET FT. FIRST WATER LEVEL-4/— r r O ❑ OUT•OF-SERVICE WELL Cl GEOM4YWCAL WELL I D/OIL BORING " B ❑0ESTRUCTION: C. INTENDED USE TYPE OF WELL CDNSiRUC710N SP£CIFICATION6 A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION I DIA,OF CONDUCTOR CASINO p F ❑ DOME$TfClRGVATE ❑GRAVEL PACKlBIZE TYPE OF CASINIIlS7EElRVC DIA,OF WELL CASINO p ❑ PUBUCJMUNICtPAL ❑.DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R 0 IIIIRIOATtONIAO i �THER ow,�� GROUT SEAL INSTALLED BY V }1 �. Z— GROUT BRAND NAME'K _ L� -'- E r LM MONITORING + _/• GROUT REAL PUMPEO: ❑Yea [IN. CONCRETE FEOESTAL BY DRILLER;❑Y— (IN. S APPROX.DEPTH f�j[jJ.T�i�f{ LOCKING CHESTER ROXMTOVE PIPE S PROPOSED CONSTRUCTIONfDPoLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Y r 1 HEREBY CERTIFY THAT I IfAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE VATH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWN,AND RULES AND REOULATtONS OF THE SAN JOAOUM COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERrORMANCE OF THE WORK FOR WHICH THIS PFRMR 18 ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'B HIFtINO OA SUB-CONTRACTINO SIGNATURE CERTtFIEB THE FOLLOWING: 'I CERTIFY THAT INTIM PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,' T 'E AbP CANT MUei A URS IN ADVANCE FOR ALL REQUIRED INS P E C TIONS AT 12041409-2422. COMPLETE DRAWING AT LOWER AREA PROVIDED. � Blened X ( / Tltfe PLOT PLM!Wow to Bcefel Beale 'to 1. NAMER OF STREET8 OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF I4OUSE SEWAGE DISPOSAL BYSTEM OR PROPOSED 2, OUTLINE OF THE PROPERTY,OIVfNG DIMENSIONS AND NORTH DIRECTION, - EXPANSION OF SEWAGE DISPOSAL SYSTEMS. S. DIMENSIONED OUTLINER AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTUREB;•INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY, � � � . . .� z :. .. . _. .. , DEPARTMENT USE ONLY _ � 4 Appllcallen Aeveptad BY Date Mea_ Oteut lnapeetlen By— ate A Itrapeetlen B Dat—ten I—F—Stan BY v , Ow. CemmdNa: l AA rr— ACCOUNTING ONLY: AID/ FACT PE CODES FEEINFO AMOUNT REMITTED CHECKRMASH_ RECEIVED BY DATE PERMITISERVICE REQUEST NUNSER INVOICE Pub,Health Serv.-Envlro.173(1197)