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PPLICATION FOR WELL/PUMP PERIL SAI_ _JAOUIN COUNTY PUBL!C HEALTH SEr.,iCES ORIGINAL� e ENVIRONMENT14L HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 / NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in TTipikete► APM.ICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITTLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PU13LICLHEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. / 2 7 JOB ADDRESS/OR APN# 1,261 eO(�l�/1' " � r_/ CITY /J/ 5J�CG" 110 /17 ��) / /PARRCEL SIZE/APNI OWNEn'S NAME 4N� /N� (NP ADDRESS /` 0 /✓P -J . t [y4-k[l, C A PHONE R CONTRACTOR_ Zt*1 U1'0 -s �k ADDRESS_ To dor ;?f2UC# _ PHONE # 707 57.3 817% SUBCONTRACTOR qq ADDRESS /S610"-r&Q r/r,1'4417 LICA T410NEtt 70 --WDC) TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL # ❑ OTHER aQ ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # ❑ New ❑ Repelt H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT -OF -SERVICE WELL ❑ OEOPHYSICAL WELL # LM SOIL BORING CIP7 a ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING D ❑ DOMESTICB'RIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC OIA. OF WELL CASINO D ❑ PUBUC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING ' GROUT SEAL PUMPED: ❑ Ym [IN. CONCRETE PEDESTAL BY DRILLER: ❑ Yes ❑ No 5 APPROX. DEPTH // SOD LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONfORILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER L -- I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN 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 WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S 141RING OR SUB -CONTRACTING SIGNATURE CERTIFIES �4 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 APPUC T Do!" -"LL 2 UPS IN ADVANCE FOR ALL REOURED INNSPEECJ,TTIO�N6 AT 12200-01 4"-S422. ,COMPPt-EE-TTEE DRAWING AT LOWER AREA PROVIDED. % Slpned X Tltle Com/,/ C"/ % �y Y U/ / Det. At�7/ (� PLOT PLAN ID- to Soslel Scsls ' to 1. NAMES OF STREETS OR ROADS NEAREST TO On BOUNDING THE 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 EX19TINO 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. APPllestlen A—mlod G-ka I—PM Ilon By Desw.tlon I-p-6on DEPARTMENT USE ONLY Dete P—P Insoeetlon By_ Dat• L O v I Arse `� D.I. ACCOUNTING ONLY: AID# FAC# l ! ' PE CODES FEE INFO AMOUNT REMITTED CHECK91CASH I RECEIVED BY DATE ITISEAVICE REOUES DER INVOICE So i��013 z5 Pub. Health Serv. - Enviro. 173 (1/97)