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LPPLICATION FOR WELL/PUMP PERIL SA. JAOUIN COUNTY PUBLIC HEALTH SEhvICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complttt In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TIT/LEE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APPiNI t I 12. C 451' QV\.I I C+�) CITY � JiS� �L.�JF�, Av�ti1 t �,I PARCEL SIZE/APN/ r OWNER'S NAME `1�-VV,i`'C .,.! CCi `yyL4V� ADDRESS 1� t7c-x S4Q"''`4 T"' W-�1�\. PIIONEN _ J CONTRACTOR_ ADDRESS It �"bUELJ ECJ Lam'. yp \_ w1� 1 LIC# S(,,L�'�C+. PHONE 1, 5'"7�;�t -Zz Z",(�, SUB CONTRACTOR F\ � � -` I✓ A� '1„ 4t k' 'il��l \ ADDRESS 37'1 Sf-L(As � `l LCA 11C# `✓ `: �c ".� PHONE 0 / / Z • �� / v TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL # ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # ❑ (TYPE OF PUMP) New 11Rep.lr N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL # W 601L BORING -3 tom- 3 e p ❑ DESTRUCTION: INTENDED USE ❑ INDUSTRIAL ❑ DOMFSTIC/PRIVATE ❑ PUBLIC /MUNICIPAL ❑ IRRIGATION/AG ❑ MONITOMNO TYPE OF WELL ❑ OPEN BOTTOM ❑ GRAVEL PACK/SIZE ❑ DRIVEN ❑ OTHER _ i CONSTRUCTION SPECIFICATIONS DIA. OF WELL EXCAVATION TYPE OF CASINO/STEEUPVC DEPTH OF GROUT SEAL GROUT SEAL INSTALLED BY GROUT SEAL PUMPED: IID Yee [IN. DIA. OF CONDUCTOR CASING _ DIA. OF WELL CASING _ SPECIFICATION GROUT BRAND NAME "� �1�' CONCRETE PEDESTAL BY DRILLER: ❑ Y• (2<o A 0 0 R F 5 APPROX. DEPTH -3-- PROPOSED CONSTRUCTIONrMLUNO METHOD: MUD ROTARY LOCKING CHESTER BOX/STOVE PIPE AIR ROTARY AUGER n CABLE OTHER U Ly-J T �'v' VN S 1 HEREBY CERTIFY THAT 1 HAVE 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 WORK FOR WHICH THIS PERMIT IS ISSUED, I SHAI L 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 WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN't COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001I'11 4400-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Tllte {�.PQlt.[ 1 1 (,L%Y�.Q,i�J�/ Det- f I I l 1 PLOT PLAN IDrew t- S-1.1 Sc -I. ' to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR Pt1OPOSFD 2. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WFLLB WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, J i S I� Ap.11c 11.n AD.mtewl By Or.ut I-p-ti.n By O.eauellen IJ..necUon B FORME a FUEL 3 LOCATi 0 N ALLEY FORM UST L HARD/NG WAY SIDEWALK ALLEY DATE I ISSUE / REVISIOt! SITE PLAN 2 EAST HARDING WAY FOCKTON, CALIFORNIA PREPARED FOR ANDREW & EDITH TRUST SCALE MOUNTAIN RANCH, CA 10 0 JO FEET SNITH IJRAWIIJO HUMBER FIGURE 2 DEPARTMENT USE ONLY Det. P -p I-p-tt.n By Date A I ! Are - Det. ACCOUNTINO ONLY: AID# FAC# �� /� I j L PE CODES FEE INFO AM UNT REMITTED 1 CASH RECEIVED BY DA PETiMIT16EAVICE REO INVOICE Pub. Health Serv. - Enviro. 173 (1/97)