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PPLICATION FOR WELL/PUMP PERM ','Q.. .OAQUIN COUNTY PUBLIC HEALTH SE, . .;CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complats In TPipl'laats) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITTLE,CHAPTER 9-1115.3\ AND THE STANDARDS OF SAN JOAOJIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNI 2 0/ 2 LJ. Yom 1 -[-L AL)q_ CITY/� I'"I�a N'-e i PARCEL SIZE/APN# 2513- 02/' (,- -,,7 OWNEn'S NAME rYG N k C r I A 4- ADDRESS 2 0 72 l�1 . y0S CSI.t Ilt' PHONE,_p�07-a3 / �s,s CONTRACTOR may,✓�A C 1� ADDRESS �S^J /�f/�t✓�L"JY�G�I,[' 1✓ �IQ1LIC CKf r�n PF10NE 18OO'�,[�-3��G SUB CONTRACTOR 'S �y I L ,yyl�• ADDRE68PrQ,pS�C I(�1�y Wr')ge,I'A4NtAvT'DUC/7� PHONE&0 373-f1/3 C-4 dp TYPE OF WELL/PUMP: K NEW WELL ❑ REPLACEMENT WELL UY MONITORING WELL/ 9 VJC I S ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL P 11New C1Ropelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) II- ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I SOIL BORINO l�OV I�qS 9 ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING p ❑ DOMFSTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEUPVC Nc— DIA.OF WELL CASINO I I p ❑ PVBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME N'MONITORINO ? � GROUT SEAL PUMPED: ❑Ye. (IN. CONCRETE PEDESTAL BY DRILLER:El ❑YM No S APPROX.DEPTH s 3o I F�IDI LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONIDRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AN0 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 W/IICH 714IS PERMIT IS ISSUED,I SIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOES(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE:;�� HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001 49!-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. oS19ned X .�{ Tltte 5 � D.I. q It ( PLOT PLAN(D• to S..I.)80.1e 'to 40 1. NAMES OF STPEETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SY97EM OR 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. T�S2�1ML ...... 1 ;1 DEPARTMENT USE ONLY /IJ Avpllc.tlon A--td By I DHe T� Are. O—A I—P-0—By Dae Pump Irnpxtlon By ().to Ow,m. —Irnoxtlon By D.I. Cnmm.,.,t.: ��AOZM, I k ` V-1VAS DTItfe Iu31EU6 (W I MniLbiATt� f ZG4 - 261s►c rz 2 o M Iz ACCOUNTING ONLY: AID# FAC/ '"- 'O'^D I� LA PE CODES FEE INFO AMOUNT REMITTED CHECK#/CAS14 RECEIVED BY DATE PERMIT/SERVICE REQUEST NLIMSEEI INVOICE Pub.Health Serv.-Enviro.173(1/97)