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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 nPir-am NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Tripikstal APPLICATION 19 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 WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 8-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. LL ` I= ^ / JOB ADDRESS/OR APNI -I J 1 - V NJ Ii 4 -e I11J rtTY 5 �Cl_K �l '✓� pear c, A,7LI�tMI• OWNER'8 NAME '1Q. �I��/o� +CC ,1St 7 ,J�Id H �1061L1 ADDRESS V IvOY�1'1 �`1 i•,1 Q^4 Lj1 ,t„,t%JA 1()�'l –F?JIONEf 71}1 (��^'7 CONTMCTOR +t C�ye o (,td � 'G FH LAI f 1� 1 M f A 1 q I ADDRE88 '10 I% IV - N' I `jm i'i ! ' UCS 640 /' S / PHONE f 14 6 -7 -to() 6 Sun ADDRESS UCS PHONE f TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CnO98-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL RECEIVED By ❑ New ❑ Repal1 N.P. DEPTH PUMP BET FT. FIRST WATER LEVEL O (TYPE OF PVMPI ❑ WELL WELL -1 GEOpIRVSIC AL WELL II ROIL BORING ❑ DESTRUCTION: �5o t MJA) ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION �•1 DIA. OF CONDUCTOR CASINO ❑ DOMESTICIPRIVATE ❑ GRAVEL PACK/81ZE ) TYPE OF CASINO/STEELIPVC r DIA. OF WELL CASINO ❑ ❑Li l,-) -c :j PUBLIC/MUNICIPAL DRIVEN DEPTH OF GROUT SEAL '1 L L ^ SPECIFICATION - ` 'I Gd p ❑ IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME C /' t d kf ® MONITORING GROUT SEAL PUMPED: ❑ Yr [IN. CONCRETE PEDESTAL BY DRILLER: ❑ Yes ®Ne S \. / APPROX. DEPTH �`' t 1. LOCKING CHESTER BOX/STOVE PIPE �' $ PROPOSED CONSTRUCTIONtMIUN0 METHOD: MUD ROTARY AIR ROTARY AUGER ' _ CABLE OTHER f� 1 HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL RE DONE IN ACCORDANCE WITN SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH C THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: ' I CERTIFY THAT IN THE PERRIO PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WONAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INS►ECTIONS AT 12061400-2423. COMPLETE DRAWING AT LOWER AREA PROVIDED. [� G� 810.8d X :��L7gJ'A. ”" _`-1 - -- Tltlp %�V1 tG.� �0 l -j �1 �0 [•li t/� 7 I Dete f I PLOT PLAN IDIaw to goals$ Soda ' to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSF. SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY. GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 7. DIMENSIONED OUTLINED AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WfTNIN RADIUS OF ONE HUNDRED FIFTY FT. (" STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DR IVEWAY8, AND WALKS. ON THE PROPERTY OR ADJOINING FIOPERTY. Appllsatlon Aooepled By Grout I—P-11— By DM1na:llen IMP'-/-- By Cemmel.ta: / � , Data DEPMTMENT USE ONLY Date _ P—P 1—p—d— By i ACCOUNTING ONLY: AIDI FACT PE CODES FEE INFO AMOUNT REMITTED CHECK/!CASH RECEIVED By DATE PERMIT/SERVICE REQUEST NUMBER INVOICE dq �5o t MJA) Pub 14ealth Serv. - Enviro. 173 (1197) J