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_ f v/ev k�o 00'vu APPLICATION FOR WELLIPUMP PERMIT S SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIt,._ ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388, SIM EAST WEBER AVENUE, STOCKTON, CA 95201388 1109) 466.3410 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION 1814ERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1F115..3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC IIEALT14 SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESWORA�P�NI I]I:V j SIV O,"h'1 C%'F- 1,J�it'Y,�.: })"�',(,�\i �� CEJ, �\il�� c1re V��i11)Q'I'L i ('� / q PARCEL SIZE/APN/ �2-Cy �/ OWNER'S NAME YT� �� (�✓/YI _ _':tV iLc_�. ADDRESS ai` ` I."71.L/ PHONE/ I CONTRACTOR �"�:i5r'c'L C `( �'(T<'i117 ADDRESS r --&jC/ / IIA PHONE I i JC SCr'4.• SUBCONTRACTOR I: 0 � e_s• 7 !` ADDRESS Tj=C��.:Z �,'J 44 "C UCI 1 rJ GL- I - t PHONE!� ' TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL 0 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL! ❑New❑Repalt H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PVMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL! ❑ SOIL BORING R ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS /� A ❑ INDUSTRIAL ❑/OPEN BOTTOM DIA.OF WELL EXCAVATION � i,NC 1 N DIA.OF CONDUCTOR CASING )VA p ❑ DOMESTIC/PRIVATE f�`J' GRAVEL PACK/SIZE ��-a't�Ci TYPE OF CASINO/STEEVPVC P(QV DIA.OF WELL CASING L n'(o 0 ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL_Z� rr CC�J�J/'c:ji SPECIFICATION (?(A(:il'� i ?""At:T -- R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY --V 0041 e, GROUT BRAND NAME-TLr t' E XMONITORING GROUT SEAL PUMPED: %Y- ❑No CONCRETE PEDESTAL BY DRILLER:Ply- ❑No S APPROX.DEPTH 60 LOCKING CHESTER BOX/STOVE PIPE 5 PROPOSED CONSTRUCTIONMAILUNO METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN 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 ISSU ,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 ERTIFV THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.' THEA CART MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1f200*1 Se5J523. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slened X �', fry`'�� Jam_TIUs��ti ` �G.f`r V1'•� 1 \-S. Date � c - PLOT PLAN)Drew to Scols)Bosle_� 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, ..,... ,_...., .. .;......:.. ..... .. .. .. ... ..°. i.. ....i.. .;....:i. .. .....i.... iz .. .., .....i_. ..... ... MW:2 4 �1 >... .. Mw S ..... : ... °.. .°..... .....>....... ............. ...... . .. . ........... .. ;. . . .. ... ...... ..... . :....:.. .: .:. . . :..... >.....:. .................. :. . — Mw DEPARTMENT USE ONLY ^� (may �7 Application Aeeopted By C�[/�''C/�/�� (/ �]i- / Oete_��" I At.. !5L Grout hhpoetlen By e{,/l�O e not. .2 Y p Impxtlon By DNa Deslruellon Impectlon By Date Comments: - �LcJ /✓i'f��s "l--p,�„-q ACCOUNTING ONLY: AIDIr FACT PE CODES FEE INFO AMOUNT REMITTED CHECKiI/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE Pub.Health Serv.-Enviro.173(3/96) I