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APPLICATION FOR WELLIPUMP PEP S- JOAQUIN COUNTY PUBLIC HEALTH S_ ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL ! (Complete In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOFOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHARTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN! sTo `, K -r O N /4 V Y=-- CITY F;iz I ro ^J C19 3 (�) W PARCEL SIZFJAPN! 5`l - 510- \ n 1, OWNER'S NAME �f' ST Lr as '4 1-� O� ' PHONE!e?' ADDRESS 6—�P•r%= C�%��'j )S�I-s�t48 ' CONTRACTr+p . .,T. 7 C G 2 JP c� a p /J Z�� 'r 5•'7 �2:•a7c7v 'VRs Y.r4.. y `ONE ADDRES6.M/i? tvL7E 22 C�9-9�r��3 UCl 53C�f-7 C'37th-39YQ PUB CONTRACTOR j P1_ -r vi . 2'7 ]!PSC tt �'7 I i. tit ONE/ # < �Co 1c3gM Dig Z "�-' L'- 'ADDRESS ='T Cr /"C 7c` N C : • 5 avZ � �} UCl� PHONE DIA. OF CONDUCTOR CASING D ❑ DOMESTICMRIVATE TYPE OF WELL/PUMP: Yll gyp' NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL!❑y ❑ INSTALLATION ❑ WELL SYSTEM REPAIR (OTHER 11CROSS-CONNECT REPAIR L1 ;7AT BIF EXTRACTION WELL I ! _ - 1 L ' Zu''� t' Cir+ ❑ New ❑ RepNr N.P. 2- :.� J DEPTH PUMP SET 4- SFT. FIRST WATER LEVEL O (TYPE OF PUMPI 00THER 1= x ' T ;'Z/i C-- 1 -''% ❑ DESTRUCTION: ❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL ! ❑ SOIL BORING R PE CODES FEE INFO AMOUNT REMITTED C NEC /CASH RECEIVED BY DATEPIERMITISERVICE REQUEST NUMB INTENDED Uhf TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑ OPEN BOTTOM < <� n1 J�=STjeIA. OF WELL EXCAVATION Z , I DIA. OF CONDUCTOR CASING D ❑ DOMESTICMRIVATE ® GRAVEL PACK/SIZE il. '3 TYPE OF CASINGISTEEL/PVC 4" S C )-{ '4f '�'/CBIA. OF WELL CASING t D ❑ PUBLIC(MUNICIPAL ❑ Dn,VEN DEPTH OF GROUT SEAL -� So a SPECIFICATION - C 114 ctl q ❑ IRRIGATION/AG 00THER 1= x ' T ;'Z/i C-- 1 -''% GROUT SEAL INSTALLED BY Spf C 7.r� ;,t.N1 GROW BRAND NAME 7L 7 ' �.'%` E 11MONITORING GROUT SEAL PUMPED: ® Yee [IN. CONCRETE PEDESTAL BY DRILLER: 8 Y- ❑ No S APPROX. DEPTH (C LOCKING CHESTER BOX16OVE PIP£ S PROPOSED CONSTRUCTION/DrtlLUNO METF'OD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT 114E WORK WILL BE DONE IN ACCORDANCE VAT" SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF TNF 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 IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$ 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'* COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUSTLL 2414OURS IN ADVANCE FOR ALL REQUIRED INSPECTIOIN$AT12001460-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. �J^ Slpned X 1 Title / I t lL M I- 6 ►'l t Data PLOT PLAN (Drew to Soelel Scale ' to I. N..^MEA OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED � 2. OUTLIwF OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. DIMENSIO—r-D OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. iT STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. \ Appllc.tl.n Aecepterl 1 Grout 1"Pp tion By_ 0-1—tlen I-0— Comore w / 9 15 �J DEPARTMENT USE ONLY Date 8!/8 Pump Inspection By_ 0,4 t.✓�O Date O — f— I?? Area V ZTr Det. ACCOUNTINO ONLY; AID! FAC! PE CODES FEE INFO AMOUNT REMITTED C NEC /CASH RECEIVED BY DATEPIERMITISERVICE REQUEST NUMB INVOICE Pub, Health Serv. - Enviro. 173 (1/97)