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PPLICATIO FOR WELL/PUMPLTH SEF{Q;PERM . r SAAOUIN COUNTY PUBLIC HEAICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NOB-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED (CBmpIBH In Triplkat�l b i. APPLICATION IS HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOWK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN } JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1 f?J 115.3�AND ,THE THE STAANDAROS OF SAN JOAOVIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESWOR A,P��NI 4! ll 1440 /I/T i'yl Q�'�'/w7^W TQ! CITY PARCEL 81ZFdAPNN OWNER'S NAME Cy-DTA-IAyS�/ � --`�f— ADDRESS rG}7 - ��!'��Lt>•.-7-�� J,� �,��, PHONEI '`S �� 1� CONTRACTOR j, C�C(�/CEJ ADDRESS�y /,V� 1"1 {yv! S ;F NE+► � ! SUB CONTRACTOR ADDRES -�+^� LICK PHONE Ap TYPE OF WELLMUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER ❑ INSTALLATION ❑ WELt SYSTEM REPAIR 0 CROSS-CONNECT REPAIR i ❑ VAPOR EXTRACTION WELL I J ❑New❑Repefr H.P. DEPTH PUMP SET FT. FEAST WATER LEVEL d {TYPE OF PUMPI 1 ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I 4 IL BORING a _ ❑DESTRUCTION: + INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION �./ DIA.OF CONDUCTOR CASINO O i 13 DOMESrICA'AIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEEUPVC DIA.OF WELL CASINO O ❑ PURUCIMUNICIPAL D DRIVEN DEPTH OF GROUT SEAL } SPECIFICATION _ J R j ❑ fRRIGATIONfAG 110 THER GROUT SEAL INSTALLED BY -Ja—lu GROUT BRAND NAM E �� LY NEON{TORihOa5-, �— GROUT SEAL PVMPEb: ©Vee e � CONCRETE PEDESTAL.BY DRILLER:GYee ONO S ! APPROX.DEPTH LOCKING CHESTER SOX/STOVE PfPE g PROPOSED CONSTRUCTIONIWLLING METHOD: MUD ROTARY AIR ROTARY AUGER 'I 4CABLE OTiHER ,3 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND AIRES AND AEOULATIONS OF THE SAN JOAOUIN COUNTY, HOME OWNER OR LICENSED AGENr'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOA WHICH t THIS PERMIT 19 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- T CANT MUST CW_14 HOURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS AT 12001 400 44 27, COMPLETE DRAWING AT LOWER AREA PROVIDED. �! I Blpned X kM7 Title ) y Dole_ PLOT PLAN Ibr to Seelel Scale 'to �{ 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOLRdOING THE PROPERTY, i� 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR T'AOPOBEO 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 'J. DIMENSIONED OLfTUwF..B AND LOCATION OF ALL EXISTING AND PROPOSED - S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY R. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. C h f DEPARTMENT USE ONLY Applreetlon Aecepted Bybel• �J V F� � +a;/ � Gree - ---_ - Groutec Ineptlen BY _, .-E� _.._.. an pate�- .... ....-.--�.•PvP'Impeetlen By— DMw.tlen IrvpeeSen y bete CemmenTf: ACCOUNTING ONLY: AIDI FACT PE CODER FEE INFO AMOUNT REMITTED CHECKIfCASN 1RECEV BY DATF PE111YIITISERVICE REQUEST NUMBER INVOICE s a Z2- __Zor s� 4 Pub.Heafth Serv.-Enviro.173(1187) } i I rl