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P, APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Trfplieat$) FEB 0 2 1999 r= till�i!T ! SE RVIC".,S APPLICATION IS 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 WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DPJISION, JOB ADORESS/OR APyNN! -�GW �V� o k:7, r K� qp 1A&;,, / C1., CONSTRUCTION SPECIFICATIONS A F CfTY /- -A SIZEIAPN! r OWNER'S NAME 60I'��f�/`�, j iA%�, A t/��c� (�.�JI1�,/�'1�y�/ ADDRESS 3�(4— l / 7I 1A � ,(P�AJR�CyEL '7) �^ r- (21is; / %/c - PN)ONE 2C' 73iC, /A�, �JI+J6fl CONTRACTOR / ^ VAxlc L= 19 C1Gt. �'-''iV V /I��y V'��V•— (r 1 `T'rA;O 112 r ADDRESS I c 5 �c,;Jh �(� �t� �ejL^�' W TUC! } �`�iL,./ LZ ! PHONE LLKI 71`i' J "/1. O - DEPTH OF GROUT SEAL �^/' T-1 IZL. SPECIFICATION R SUN CONTRACTOR El OTHER ADDRESS UC! PHONE / D TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONFtORINO WELL ! ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑ New ❑ Repalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PVMPI ❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL ! SOIL BORING S ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A F INDUSTRIAL 11MA ❑ OPEN BOTTOM w DIA. OF WELL EXCAVATION ZI• NJ i.'TN y� / 1 / V DIA. OF CONDUCTOR CASINO 0 ❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASINO/STEEUPVC py L- DIA. OF WELL CASING Z //V D ❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL �^/' T-1 IZL. SPECIFICATION R 11 IRRIGATION/AO El OTHER GROUT SEAL INSTALLED BY ry - GROUT BRAND NAME Lir, T t/'t/�`y 0 E D GROUT SEAL PUMPED: ❑ Y« BW. CONCRETE PEDESTAL BY DRILLER: ❑ Yw 12< S MONITORING �! �- APPROX. DEPTH r LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HE -ERY CERTIFY THAT 1 HAVE PREPARED THIS AFPIJCATION 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! '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WI11CH THIS PERMIT 18 ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$ COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUR -CONTRACTING SIGNATURE CERTIFIES (Z THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH T1418 PERMIT 19 188VED, 1 SHALL EMPLOY PERSONS SUBJECT 70 WORKMAN'S COMPENSATION LAWS OF - CAUFORMA." THE APPLICANT MUST CALL 24 bOLRLS IN ADVANCE FOR ALL REQUIRED IN$►E MNe AT (2001 Hee4422. COMPLETE DRAWING AT LOWER AREA PROVIDED. _ Sl/ned x YjTz TM. (^I '(w � e PLOT PLAN (Draw to Bealel Boal• . 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, OIVM10 DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTUNFB AND LOCATION OF ALL EX19TM G AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES, MICLUDINO COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. / DEPARTMENT USE ONLY l�J (� Appllastlen Aooepted BY '��(�� `/ D.ri/ MY 0 L T" / J Grout (—pool.. BY ( "JJ�� ,�e Q �� Date , �5 %LJ Pt p Inspoctlon By --Data Omef,mtlen I-pection 8 Ce or,w Dsre ACCOUNTINO ONLY: AID! FAC! PE CODES FEE INFO AMOUNT REMITTED CHECK11CASH I RECEIVED SY DATE PEMIT/SERVICE REQUEST NUMBER INVOICE Jl�%v'I 77(4w Pub Health Serv. - Enviro. 173 (1/97)