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APPLICATION FOR WELL/PUMP PERIQNNE SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES W i'� �� ENVIRONMENTAL HEALTH DIVISION PC 304 EAST WEBER AVENUE, STOCKTON, CA 95202 7-0, zr (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED j { ICamplets IN Trklkwiml APPLICATION 18 HERE BY MADE TO THE BAN JOAQUIN COUNTY FO A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, APTER u 15. AN EST D OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ji94 L.iQ a/N f� r J JOB ADDRESWOR AYR/ CITY 57aGLny,-J � r PA/RCL SIZElAPNI OWNER'S NAME 17 L ADDRESS 412-5- /V /7-L 7-7--PHORE! 3. 7,f Tde. CONTRACTOR A ADDRESS KmiJ/ iia LICI PHONE SUB CONTRACTOR �N� sr /�/] ��p. /LI4/i a!/� ADDRESS IL- 1 61< PHONE �nu�r� inn ra -- >"b GIL 77!AIV9& 6;z wrr TYPE OF OF WEI.LIPt1Mp, ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONrTORING WELt 1 13 TW"' ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 1 ❑ ITYPE OF PUMPI New 11Repa11 H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL 1 SOIL BORING g INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION!— miw�nni�.ar ��-- "' A © INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING p ❑ DOMESTICIPRIVATE ©GRAVEL PACXIS12E TYPE OF CASINO/STEEL/PVC CIA.OF WELL CASINO O ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIOATIONIAG O//T--HER GROUT SEAL INSTALLED BY r GROUT BRAND NAME E ❑ MONITORING GROUT BEAL PUMPED: ❑Yea CI Ne CONCRETE PEDESTAL BY DRILLER:11Y. ❑Ne S orf 1 APAIO X.DEPTH__-I S/- " a LOCKING CHESTER BOX/STOVE PIPE s PROPOSED CONSTRUCTION/DRILLTNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I"MRY 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL 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 IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS O� CALIFORNIA.' APPUCANTYif -UrALL 21 HOURS IN ADVANCE FOR ALL REQUIRED INSFECTR)NS RAT 11220410148110 c423. COMPLETE DRAWING AT LOWER AREA PROVIDED..^ Signed X _s _, , - TIft PLOT PLAN(Draw to Sada!Seate 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 1, LOCATION OF HOUSE SEWAGE 019POM SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENBIONB AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. G. 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, . � _ Il - _ :•:_ 6 y In it 4 j' i1- Y i / 14� I \•.• s� A o ■ r ik tilt • % `\` / Ines T I in d 1\ n 41, Jl x Z' l u�c�2 F 3r-lT` �^/ (5 _ 141,998 i .... DEPARTMENT USE ONLY - - L - _. ApPlkatMn Aeeepted 8Y — C. Ar O-ut MnPeatlen By Date PtanP Irrpeetlan BY Dale Destrtretlen Inspection BY Date ACCOUNTING ONLY: AIDI FAC/ PE CODES FEE INTO AMOUNT REMITTED CHECKIICASH RECEIVED BY DATE PEIWBTIS"MCE mou"'t3mirmeffivi INVOICE s :Sb r SCS S� Pub.Health 5erv.-EnViro.173(1/97)