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►PPLICATION FOR WELL/PUMP PERIL SA,=JAQUIN COUNTY PUBLIC HEALTH SEN,I.ICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 MON•REFUNDABLEPERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicab) 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 JOAOLIIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS, 1OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# H' `R O �AV V , ` A Y '� 4C I= M E C E r Y I- A ,VF- CITY`` �Iy7, I C C I-` ( C 1 �.{ ` g,� PpARCEL SIZE/APNI OWNFn'S NAME S r11r J c; A G'ji ti C {, V_ j ,,, K �, 1,_ �' E �\ ADDRESS I, U. o x I' Z I 11' l li J LCI PRONE / y�YT/ � j t CONTRACTOR �/ �L' O c% 0- � 1 1,A `% ADDRESS (i EJ .� I r\ I C ,y i 5 F A UCJ 1 2C 9 a PHONE I 3,4 SUR CONTRACTOR ADDRESS �� I UC# PHONE # TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL Z 0 MONITORING WELL # L' •� �� ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I _ J ❑ New 11 Repel/ H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF M/MPI ❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL. WELL I ❑ SOIL BORING R ❑ DESTRUCTION: INTENDED USE TYPE OF WELL -CONSTRUCTION SPECIFICATIONS (] e A 11 INDUSTRIAL ❑ OPEN BOTTOM .yµ�. /. 1) DIA. OF WELL EXCAVATION y> I N C� DIA. OF CONDUCTOR CASING 7 N A L D `\ ElDOMF.9TIC"IVATE ® GRAVEL PACK/SIZE - SAN TYPE OF CASINO/STEELJPVC �y�+,,t� 1-. J L DIA. OF WELL CASINO I N G • 1 p El PUBLIC /MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL 3 o f C c 7 SPECIFICATION ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY Lj ', i t- t- C 't'L GROUT BRAND NAME �( 9=II �• \ h '� �� L. �E j t MONITORING GROUT SEAL PUMPED: 0 Yee ❑ No ( CONCRETE PEDESTAL BY DRILLER: ❑ Y- N No APPROX. DEPTH r� S- I. r- l LOCKING CHESTER BOX/STOVE PIPE ] S U �ti 1 I I I, Ir 5 PROPOSED CONSTRUCTIONIDAILUNO METHOD: MUD ROTARY AIR ROTARY AUGER X ` CABLE OTHER r I HF4PBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND _l nEGULATION9 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 WHICPI THIS PERMIT IS ISSUED, 1914ALL 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 IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQURED INSPECTIONS AT1 12091409-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. / (� Slpned X l •'awt/'--9' Tltls iL IJ / ENV, { L 1\I? \i 1.. t AN Dete .I > t P ►i , /� M �+ �' > t (T jl � PLOT PLAN (Drew to 8.0.1 Seel. to 1. NAMES OF STREETS OR ROADS NEAREST TO On 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 HUNDnFD FIFTY FT. STRUCTUnF.S, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY On ADJOINING PROPERTY. Doebuetlen ,(jjjJJJ/�0 DEPARTMENT USE ONLY Appllcetinn Aee.pteA By / ',L��"-"�../ \ Delo lJ A,. `• D-" Grote I.,p.alon By P—P Inepec0- BY DNe 1— 11- Ry D.I. ACCOUNTINO ONLY: AID# FAC# 3�Q' PE CODES FEE INFO AMOUNT REMITTED CHE # CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 3 01 1160 i Pub. Health Serv. - Enviro. 173 (1/97)