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s APPLICATION FOR WELL/PUMP PEP � T JOAQUIN COUNTY PUBLIC HEALTH : VICES ENVIRONMENTAL HEALTH DIVISION' 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compbta in Triplieata) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DEECRIBEO. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN/ J 17 %i f CITY r � 5 tJ 4 y 3t�l <61PAARCEL SIZE/APN/2 OWNER'S NAME /LJ (� _Cj LTA... ..t S.4 ADDRESS ,�.i;.i D :v� 'Q -, �G'� � ( ONE #�.�j d'� _ �JA O PHONE R !"'� CONTRACTOR i "'? t Civ .2P.:"�Z4 i-')c�.ti 5 7 .4 R: V•� �A C'!:. S7 ADDRESS '1'4'l t?T: �.>r -4=f -1-a _S'3 UC# 534%/-Tc7PHONE/ 0rf;' q 13-70_.3770 SUS CONTRACTOR &U rZ� 5 " j 1-i4 �Z r -1l} -% I>T` ,C' Sz33 i=t 3c>>z %2 �L t+ 5t. 4^CC . D`1c 74,.�,A DEPTH OF GROUT SEAL L , SPECIFICATION R 7Id-t_ ' t c:t ❑ OTHER TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 0 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # J ❑ New ❑ Rep.I/ H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL 0 SOIL ROBING J g ❑ DESTRUCTION: INTENDED USF TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑ OPEN BOTTOM J DIA. OF WELL EXCAVATION 1 O/ DIA. OF CONDUCTOR CASINO D ❑ DOMESTICR'RIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC ,ili'1 DIA. OF WELL CASINO /LJ `7 D ❑ PUBLIC /MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL L , SPECIFICATION R ❑ IRRIGATION/AO ❑ OTHER GROUT SEAL INSTALLED BY ' n1.4L4 1 GROUT BRAND NAME ,, f ),01n c , E ❑ MONITORING GROUT SEAL PUMPED: Ia Yee [IN. CONCRETE PEDESTAL BY DRILLER: ❑ Yee ON. S APPROX. DEPTH �' �' �' LOCKING CHESTER BOX/STOVE PIPE -,t,'f Q- S.,. PROPOSED CONSTRUCTION/DAILUNG METHOD: MUD ROTARY. AIR ROTARY AUGER CABLE OTHER 1 HE'tERY CERTIFY T14AT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES ANDD nFOULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED, I SHALL OT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB -CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: ' 1 CEITTIFYXtOT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 10 ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COPAPEN19ATION LAWS OF CALIFORNIA.' THE APPUCA UST 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT I�8lpped X. V p1200) 400J42J. COMPLETE DRAWING � AT LOWER AREA PROVIDED. i L� /Cel veDne \—� "PLOT PLAN (Drew to goal.) Selo ' to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING T14E 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 HUNDRED FIFTY FT. STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. DEPARTMENT USE ONLY G �1 ApPllcoticn Accoptorl Ry (�Q (/ Det. 7 -7 Arse </ 7�J0 Grout IMpoctbn By U. t. tlor. Imne^Uon By Dae Pump Inspection Sy Dole ACCOUNTING ONLY: AID,# FAC,# PE CODES FEE INFO AMOUNT REMITTED EC #/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 8�� 8ci Ik(1-7 Co C,lk-41s_s Pub, Health Serv. - Enviro. 173 (1/97)