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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 II NON-REFUNDABLE PEAAUT EXPIRES 1 YEAR FROM DATE ISSUED 1, {CamplBti In TRiplki!&} ; APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PEFIMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1116.3 AND THE STANDAIM9 QF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMSfON, JOB AODREBSlOR AP}N&'O V- CITY .].. i PARCEL SIZEIAPN& 195—�3^ 1 OWNER'S NAME �IIA = [:��tr5 � ADDFtE88 .O� �� Z�� PHONE V2149 W6 CZ416 CONTRACTOR �! I �: cr'.3 P '� (; ADORE88�9 S- @, I - ✓alk-3 S UC&C CtC- PHONE or .G -11Z 3 C SUBCONTRACTOR II ADORE88 -i EIC• PHONE TYPE OF WELUPUMF1 ❑ taw WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL& ❑ OTHER I� ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR E%TRACTION WELL& J i. ❑ N.❑RapaN H.P. ItYT'E OF PUMPI DEPTH PUMP SET FT, FIRST WATER LEVEL O ❑ OUTOFSERVICf WELL ❑ GEOPHYSICAL WELL& BOIL BORING g ❑DESTRUCTION: :I INTENDED USE TYPE OF CDNitRUCTION iPfCIFICA ION{ A ❑ INOUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION. Idi Ll'i DIA.OF CONDUCTOR CASING_�I�� D ❑ Dom ESTICMMVATE ❑GRAVEL PACK/MZF TYPE OF CASINGISTEEUPV'CA`A- 11 DIA.OF WELL CASING _ D ❑ PUBLICIMUN(CtPAL 11 DRIVEN DEPTH OF GROUT SEAQ—C%kI {, S' p_ SPECIFICATION } A ❑ IRMGATION/AO '� ❑OTHER GROUT SEAL INSTALLED BY'r -ti !�. GROUT BRAND NAME c 1 E ❑ MONITORING `' GROUT SEAL PUMPED:p Yea ❑No CONCRETE PEDESTAL 8Y DRILLER:©Yae []No 5 APPROX.DEPTH k ' �. _ ._ LOCKTNG CHESTER BOXJBTOVE PIPE S .I PROPOSED CONSTRUC!TIONRTWLLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE --a' •'-(Q' 1 HEREBY CERTIFY THAT I HAVE PI$PARED THIS APPO UCATN AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF TNT SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICN THIS PERMIT IS ISSUED;1 814ALL NOT EMPLOY PERSON8 SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'i CEITrIFY!_"PERFORMANCE OF THE WORK FOR WHICH THIS PERMtT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOIOUMAN'S COMPENSAHON LAWS OF CAUFO IIE APPIIC MUST C LL Z,HOURi IM ADVANCE FDR ALL REOVIRp rNs/ECTNp)NlI�AT�{ 1Q,p��I2�3�COMPE,ETE DRIhYVINO AT(OWER AREA PROVIDED. Blpned X T1tls Oala� �i PLOT RAN(Dew to Scel-t Scale 'to , 1. NAMES OF STREFTSi OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PHOPOSED 2. OUTLINE OF THE PTIOPEIKTY.GIVING DIMEN510N8 AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTdNF.B AND LOCATION OF ALL wirrma AND PROPOSED S. LOCATION OF WELLS WfTMRE N RADIUS OF ONE HUNDRED FIFTY FT. STRUCTiTRES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOMINO PROPERTY, .. . :.. . ....... .. .. . ... .. ... .. Y -- .. ...,. .,.. ter. ,�.r:•.—. .. _ .. - ... _ �:- -::. _ �.:...:.-, ;....;.- .; ' II DEPARTMENT USE ONLY r Application Accepted BVI! Det- epNee 7 S 1C+ of""pecti-n BY Date Pimp b"ectlen By pate i� O"Intellen Impaction BY Date Cemmente: ACCOUNTING ONLY:i AID& PAC& PE CODES FEE INFO AMOUNT REMITTED CHECKSMASH RECEIVED BY DATE PEItMITMERVICE REQUEST NUMBER INVOICE Pub Health Serv.-ErAriro.173(1197)