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T'PPLICATION FOR WELL/PUMP PER • SAMbAQUIN COUNTY PUBLIC,HEALTH SERTICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON, CA 95202 (209)468-3420 N0N•REFUNDABLE PERMIT EXPIRES I YEAR FROM.OATE ISSUED MmIsiEb IN TTiplidsts) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO COtN9TRUCT ANoIOR INSTALL THE WOW DESCRIBED.TGOB APPLICATION IS MADE M COMPLIANCE WIT if SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND tHE sTANDARO9 OF SAN JOAOUBN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADOREss1oR APNf 5 0 3 E A s r T E N T F{ S T R E F Y Crrr T R A C Y PARCEL MMAPNI 23 S- 19' L 3 OWNER'S NAME,C O 0 N T Y OF AAI T A vtN ADDRESS 2VL E WE.-11ER AVE- 4TF1 FLGOR PI.ONE/-(209)46.8-8910 sTOC.tcTOtJ, CA 9510 Z09 }-11-3540 ` CONTRACTOR F I S C H E IJ v(R 0 M E r+T A L. ADDRESS 5 E I'S P L A C LICE C.: 5} PHONE VALLEYSPRING , GA tt663865 Live CONTRACTOR ADDRESS -9 S 2 UGI PHONE f l TYPE OF WELtlP1fMP ❑ NEW WELL ❑ REPLACEMENT WELL. ❑ MONTrOFUNG WELL f I OTHERwV EO P RO G 1= ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAM © VAPOR"TRACTION WELL f J � New 13Repelr H.P. - DEPTH PUMP SEi FT. FRROI WATER LEVEL— El O I[' IT YPE OF PUMPI' - ❑ OUT•OF•9ERVICE WELL 0 GEOPHYSICAL WELL+ ❑ som Sown s ❑DESTRUCTION: INTENDED U6E TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ tMMSTRIAL ❑OPEN BOTTOM - DIA_OF WELL EXCAVATIoH 'Z" I OtA.OF CONDUCTOR CASINO M O N A DIA.OF WELL CAS040 N a P asINGr9TEELrPVC � A-- ❑ DOME971CIPWVATE ❑GRAVEL PACKls12E TYPE O C - ❑.PUSUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEM_ TOTAL DEPTH _ SPECIFICATION NA R r ❑ iRRIGATIONIAG ❑OTHER GROUT SEAL mnALLED BY G0 NT R A C T 0 R GROUT BRAND NAME F ❑ MONITGRINtT GROUT SEAL PUMPED. 0 Ywr' ❑Ne CONCRETE PEDESTAL BY DR1114 t❑Yw ■Ne s APPROX.DEPTH '2O F T. LOMING CHESTER BOXMOVE PIPE_ a PROPOSED CONSTMM 170NIDRIUUNG METHOD: MUD ROTARY AIR ROTARY AUGER CAME OTHER -SOIL AND GFtOvNDWATSR (rRA13 SAMPLIAJCr / SAME— DAY ABANDONMENT -_ 1 HEREBY CERTIFY THAT 1 NAVE PREPARED TWO APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND t REOULATIONs OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTSTES THE FOLLOWING:'T CERTWY THAT M THEMEWORMANCE OF THE WORK FOR WHICH I!I THIS PERMIT 19 ISSUED,I SHALL NOT EMPLOY PER90NO SUBJECT TO WORIMAMS COMP@ISATTON LAWS OF CAUFORFDA.- CONTRACTOR'S WMM OR 9UBCONTTMCTBNG SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN TIIE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIWIAN'9 COMPENSATION LAWS OF Il CALIFORNIA.' THE APPLICANT MUST CALL 24 HOLM IN ADVANCS MR ALL REQUIRED DNEFECTIONS AT T2"I 49642922. COMPLETE DRAWING AT LOWER AREA PROVIDED. st•ned x TI,e�C o N S U L T A N T T A tr ENS 10 1 7.9 19 1 Ta S E t'W R A M A G E PLOT PIAN M,M to SeYel SG46 to I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <. LOCATION OF HOUSE SEWAGE otSPD9Al SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DIW09AL SYSTEMS. 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXI9rWG AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Fr. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, S E...E. A ': T:T 'A C ;H ::..D S. .f. .r...E,. p ;�-.:.A..N...... t. . S -.. -: ,..: .. - I DIWAMMENT USE ONLY .. AeplleetlGn Aemwtsd"' A'en�Q lM10 a Moo { G*o,rt I,xpeGll•n By Dela Ptow InepeetleR my veto D-In,Gtlen Mopeetlen BY DDatt�e o wv A Q .. ACCOUNTING ONLY: AID# :6 FRCP - - , PE CODES FEE INFO AMOUNT NMITTED CHMK#ICASH RECEVED BY DATE PERMITPSERVICE REQUEST NUMBER INVOICE Pub.Health Serv.-Erwiro.173(1/97