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'APPLICATION FOR WELL/PUMP PER& ' SA. JAQUIN COUNTY PUBLIC HEALTH SE. ICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 / (209) 468-3420 Q// We, Rle jNONPEFUNOABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FORA PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR -SL"'(� I w � �= 5� CITY y� � �..� PARCEL SIZEE//APNO nAP^NI_ OWNER'S NAME�Y\ LI S t \ ADDRESS `21_ t t \ �� l 4 t� �E��i •�I N ti-, PHONE CONTRACTOR `3f �^C�r' \"F- �(�li tGf�YV�P YAP', [i1� VL!' 1" ADDRESS `^D- 1 �� ('� LlCI SUBCONTRACTOR --')cc-- '(-uyy\ eXn�Of-tL'k cr\ °�`vL ADDRESS ry-3CC��J�f ! ILi CL yY\ {oj.J� LICA`_.1 3iu� PHONE,3kcl SPECIFICATION ❑ IRRIGATION/AG TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONrTORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I 11New 11Repelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 (TYPE OF PVMPI CABLE OTHER Y e.CA- ❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL # '94- SOIL BORING ❑ DESTRUCTION: r INTENDED USF TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING ❑ DOMESTIC/P NATE ❑ GRAVEL PACK/SIZE TYPE OF CASING/STEFL/PVC DIA. OF WELL CASING ❑ PUSLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL_ SPECIFICATION ❑ IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME ❑ MONITORING GROUT SEAL PUMPED: \I'/ea ❑ No CONCRETE PEDESTAL BY DRILLER: ❑ Yea [IN. APPROX. DEPTH LOCKING CHESTER BOX/S"FOVE PPE PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Y e.CA- A O D R E 5 S I HERESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL HE 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: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR( FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{ COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUS -CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: " I CERTIFY THAT IN THE PERFORMANCE.RF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{ COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ANCE FOR All REQUIRED INSPECTIONS AT 12091469-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. \ AAAA 8lpned X f Tltle . / I U.'�-r!-�`� Data 1 \ 1 �J (D PLOT PLAN to,— to Soalel Scale ' to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM 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 WrIA 8 WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. DEPARTMENT USE ONLY Applicalinn Acceoted By Grout Impeotlon BY [\n P1� Cl\ ' Date 5 -z O Pump I-P-0on Ooat—fl- In•r- lnn Sy Comments: Date 1 _L Area Data ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED By DATE P E/9ETiVTCElIEO INVOICE S O OD 9 `6 2 L Z (9 S Pub. Health Serv. - Enviro. 173 (1/97)