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'APPLICATION FOR WELL/PUMP PERM' SANWOAQUIN COUNTY PUBLIC HEALTH SER4,(CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplkete) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITL^E,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. JOB AODRESS/OR APN# 2 LQ' �` J� n�a w� �� ,�1 (amu)��CITYCTI ^tomI c r�)c 4-, n '/ PARCEL SIZE/APN# r, OWNER'S NAME_MR 514 And \i h cA } R A 1L[ g o )J ADORE88 (-�, ) )—xl•L1� 3-b �/ 7 PHONE t 9 /;9 5 -00 CONTRACTOR a�ATdcED GR tt AV;f()rtMPn ll /11[ ADDRESS_ 6 Z,Z PHONE ZO7 (Q 'pzbcy CUB CONTRACTOR ! / ` t ren A ADDRESS c CK ^ I i LO IJCff 6PHONE I TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# (TYPE OF PUMP) 11 Now❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D // 11OUT-OF-SERVICEWELL ❑ GEOPHYSICAL WELL# SOIL BORING BTS a ❑DESTRUCTION: INTENDED USE TYPE OF WELL -- CONSTRUCTION SPECIFICATIONS '1 •, A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION - ,C%J DIA.OF CONDUCTOR CASING 1x/09 D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELrVC NIA. DIA.OF WELL CASING N////IT D ❑ PVBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL:rO4.0DI J)C Y I (N SPECIFICATION -}� R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY '70^'E M&PoID GROUT BRAND NAME I / C E ❑ MONITORING ^ cL �" /� GROUT SEAL PUMPED: KI Yea ❑No CONCRETE PEDESTAL BY DRILLER:MY" []No S APPROX.DEPTH0_1p ` FiEGC 7 ,J,v' LOCKING CHESTER BOX/STOVE PIPE AJI& S PROPOSED CONSTRUCTION/DRILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT 1 NAVE PREPARED THIS APPLICATION AND THAT THE WORK 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 WOW FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-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.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION$AT 11001400-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slpned X ` Title (/��,,��V\L 1A PLOT PLAN IDraw to Scolel Soule 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. 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. Xn.n .......� ....; :.....;.. .�......?.. . ......?......?.. i..... ... o.........:..... i.. .c... .. .. : . : . - u ...... . : � . / .. .................. ......... .. 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DEPARTMENT USE ONLY ADPllcatlon Accepted By Date vs_h) Area Grout Inopoctlon By Dote Pimp Inopeetion By Date O-miction Impeetlon By Dote Comments ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED C #/CABH RECEIVED BY DAix I ,PEEFIMIT/SEnVICE REQUEST NUMBER INVOICE Pub.Health Serv.-Enviro.173(1/97) L-