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SA. .)OUIN COUNTY PUBLIC HEALTH sa CES WPLICATION FOR WELL/PUMP PER ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE. CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNI 5 C 3 EA >1' 'TEN rill STK E CITY TRACI PARCEL 9IZE/APN0 23C19 - 15 'S NAME C 0 'i ?'.1 II 0 F CA psi ;ICA U. t.,', ‘ N 1-11 k.• VI e $1,.e c Av i t 1 Gm I 11;1/, .4" ADDRESS S I'D i'.._ tE, t-G.."1 4 ....- /4 2 5 I. c 2. PHONE ir 409 , 4.6 ? - E 410 OWNER CONTRACTOR V I w 0 i-k I ILI tsi 1,i- r t,51,, „ ","." 1.1/1.0111,a ADDRESS p.;;I:2 v i 4. ra.., 1..1% - 717 t 1 Lir, I z.v., v 'T PHONE S 101' .3 -i it . lg 15' SUB CONTRACTOR ADDRESS 1.1C0 PHONE TYPE OF WELUPUMP: VNEVV WELL 0 INSTALLATION 0 New 0 Repair (TYPE OF PUMPI INTENDED USE TYPE OF WELL INDUSTRIAL 0 OPEN BOTTOM ...4. DOMESTIC/PRIVATE (RAVEL PACK/SIZE 1+3 Sqvist. PUBLIC/MUNICIPAL 0 DRIVEN liMONROFIING WELL 0 PAW- I CI CROSS-CONNECT REPAIR DEPTH PUMP SET FT. CONSTRUCTION SPECIFICATIONS DIA. OF WELL EXCAVATION 8- tick TYPE OF CASING/STEEL/PVC P V C DEPTH OF GROUT SEAL - 17t OTHER VAPOR EXTRACTION WELL FIRST WATER LEVEL SOIL BORING A DIA. OF CONDUCTOR CASINO NA DIA. OF WELL CASING 2_ - kcit SPECIFICATION SC let R REPLACEMENT WELL WELL SYSTEM REPAIR H.P. OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL 0 0 DESTRUCTION: IRRIGATION(AG 0 OTHER GROUT SEAL INSTALLED BY Treivtge GROUT BRAND NAME Ntlqf Cs?. '61,1 t41- E eMONITORING GROUT SEAL PUMPED: 0 Yee 121% CONCRETE PEDESTAL BY DRILLER: 0 Yee 13/No APPROX. DEPTH io Feel' LOCKING CHESTER BOX/STOVE PIPE Fii>11 trtei AIR ROTARY AUGER X CABLE OTHER PROPOSED CONKTRUCTION/DRILUNO METHOD: MUD ROTARY I HE 0EIVE CERTIFY THAT? HAVE PREPARED THIS APPLICATION AND THAT THE WOR( WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES, STATE LAWS, ANO RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY REIONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S temp OR SUB CONTRACTING SIGNATURE CERTIFIES THE FM I OWING. 'I CERTIFY THAT IN THE RFORPAANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'APPUCANTUST CA 24 HOURS IN ADVANCE FOR ALL REQUIREDINSPECTIO S AT IMO) 4114-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. f)(7 lry) TItl )i.f? E.20 ' Data /-6,) --a„ -9s) (-3) SIX PLOT PLAN IDrow to Seale) Scale 1 NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. (0 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM on rnoroSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT ON THE PROPERTY on ADJOINING PROPERTY. Ar C r4A DEPARTMENT USE ONLY 1 eq 1.1 Grout ImpOctiOn ST (.,X.4 -11./Vv"‘" Dote 0 2.51 Pump Impaction By Data trarpaction By Dote Comments: ACCOUNTING ONLY: AIDS FAC0 PE CODES FEE INFO AMOUNT REMITTED CHECK0/CASH _., RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 3 So / ii .2 cl,o0 OA to 2.1-1t3 _0 l -R-355 S-R--00/-75S-S— Pub. Health Serv. - Enviro. 173 (1/97) Accomtexi By rot,. Dots Area