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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 ORIGINAL (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CempMte in TripRedts) APPLICATION 19 (HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH Df JOB ADORESS/OR APNf 2-D6 i1M,.,, I ,!n_ZZ11 W�.f��, -SI CIT^vfY,^ /V�-//y ��P,A�RRCEL S12E/APNf }7F•CQ=��7T OWNER'S NAME�IJ� I�LCJI(.]1c l.Q . INL ADDRE 88 1 •y. �+ / , 1 T�:�I 95 2b -� PHONE II — /_! /O 11 CONTRACTOR ��•E AUDAE 88 y'rCti5 N. ry�(^S��'y�r� LICE&goaa-) PH.NE BUS CONTRACTOR ADDRESS ✓�/V L. 4 ys2Q} UCS PHONE TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL f ❑ OTHER FACT ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CR088-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL f J DATE ❑ New ❑ Rop W, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O 47-3 (TYPE OF PUMP) ❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL # /�-� WSOIL BORING ❑ DESTRUCTION: INTENDED USE 11 TYPE OF WELL 11 CONSTRUCTION SPECIFICATIONSw A I INDUSTRIAL OPEN BOTTOM DIA. OF WELL EXCAVATION .12 DIA. OF CONDUCTOR CASINO',/" ❑ OOMESTICRRIVATE ❑ GRAVfN PACK/SIZE TYPEDEPT OIA. OF WELL CASINO ❑ PUBLIC/MUNICIPAL / OF GROUT SPECIFICATION R ❑ IRRIGATION/AO ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME 027„!fiN�> E ";,p MONITORING GROUT SEAL PUMPED: ❑ Yeo 0 Ne CONCRETE PEDESTAL SY DRILLER: ❑ Y« ❑ No S + APPROX. DEPTH [� LOCKING CHESTER BOX/STOVE PPE AL, Cf S PROPOSED CONGTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 41407- I iI HMBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN 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 Id ISSUED, 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$ COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: CEITTIFY THAT M TUE PERFORMANCE THE WORK FOR WHICH THIS PERMIT IB ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' C M� 24 NOIRq 1 ANCE FOR ALL REQUIRED INSPECTIONS AT 12001 4604422. COMPLETE DRAWING AT LOWER AREA PROVI ED. � stq t X Title �� - Date ` 1 PLOT PLAN (Drew to Seolel Soele ' 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, OIVMIO DIMENBIONNS,AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED E. LOCATION Of WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOtNMO PROPERTY. Applleetion AlroePled By - Grout Ir pectlon By_ Doew.tlon I-pp—tionBy eD CommdHe: aJ7t--4- Det. DEPARTMENT USE ONLY P—P Impectlon By Dete A, o� 061. ACCOUNTING ONLY: AID# FACT PE CODES FEE INFO AMOUNT REMITTED CHECK#ICAEH I RECEIVED BY DATE d INVOICE p r 47-3 Pub Health Serv. - Enviro. 173 (1/97)