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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 (209) 468-3420 ORIGINAL po�ziz, DEC 3 1 iggg NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Campleta In TrIplieals) 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 WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN/ �Z 150_ _ CC)\fr4r-,l C) \ 6 F/ /,f F), CRY STO C k To 0 PAREF1 A17F/AM N OWNER'S NAME _ Jn E R j 1/^R N j� ADDRESS / I O. L)C)X q,35 (0 PHONE 120- 99-3- 133'sCON7RACTOR Ad�jA[\KQ.� `?I?O�nTIC- V;MfNl, ME: 'SADDRESS 9005 N. tVj'ISQnWAYUC/ 6RIDZZ7 PHONER2aj-Vb7'/Cf� SUB CONTRACTOR ADDRESS uC7 PHONE P TYPE OF WELL/PUMP:NEW WELL ❑ REPLACEMENT WELL �MONROFU WELL I M L -J -S ❑ OTHER INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ ❑ New ❑ Repolr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL /S 4,f C T 's SC, U (TYPE OF PUMP) ❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING S ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS 1_ ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION (SIR - I,AG n DIA. OF CONDUCTOR CASING N/� ❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASINO/STEEVPVCC r C``/ �^ a c DIA. OF WELL CASINO 2- - 1)[ /I ❑ PUBUC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL A A f)F- 40 `FDQT.1fJJ^F SPECIFICATION S E� E n ❑{ IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY I �R M 11E- MZ TI`0 L GROUT BRAND NAME O ) 09 N 10 ldJ MONITORING !/L� GROUT SEAL PUMPED: ❑ Yw 9Ne / CONCRETEPEDESTALBY DRILLER: j8,y- ONO APPROX. DEPTH O, 127 5 G LOCKING CHESTER BOX/STOVE PIPE O(, I will &.7 / \ PROPOSED CONS TRUCTIO N/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY OROINANCES, 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 WHICFI THIS PERMIT IS ISSUED, 1 814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: ' 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED. 18HALL EMPLOY PERSONS 8U9JECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' T/H�EE APPLICANT MUST CALL 24 "OURS IN ADVANCE FOR ALL REOUIRED INSPECTIONS AT ("01144003423. COMPLFTE DRAWING AT LOWER AREA PROVIDED. BlOned X_ Tltla'T PILOT PLAN 101tNv to S-41 S-1. ' to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED c)2. OUTLINE OF THE PROPERTY, OIVM/G DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOM SYSTEMS. J. DIMENSIONED OUTUWR AND LOCATION OF ALL EXISTING AND PROPOSED E. LOCATION OF WELLS WITHIN RA.OIUS OF ONF HUNDRED FIFTY FT. AppllaHlen Amopted I Grout I—peetlen By DMIIIICfIOn I—pp—tIon Comments V/'fi►' DEPARTMENT USE ONLY Det. Pump Intpeetlon By Det• / � Ar" Owe 1/S/ C.. C4.e ACCOUNTING ONLY: AID/ FACT ' // PE CODES FEE INFO AMOUNT REMITTED CFIECK/ICASN I RECEIVED BY DATE P6MITISEAVICE REOVES INVOICE SOD �a Z I Pub Health Serv. - Enviro. 173 (1/97)