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APPLICATION FOR WELL/PUMP PERMIT <br />Si 'OAOUIN COUNTY PUBLIC HEALTH S ICES <br />ENVIRONMENTAL HEALTH DIVISION <br />304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br />(209) 468-3420 <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />ICompl{te In Triplicate) <br />APPLICATION 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 WrTH SAN <br />JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. <br />JOB ADDRESS/OR APNI 639 W. c lg y j r j 'Qi r <br />CITY 5 ! 6 (14 1' 0 Y\ <br />PARCEL SIZE/APNs <br />r <br />OWNER'S NAME T G ky <br />proi+'r rl 'e � <br />ADDRESS P b• 8o X 61 , <br />p� <br />y // y <br />5 1Uc 1"j loin PHONE R � 4 0 30 <br />/�W-1 <br />CONTRACTOR. /Tt�V(?!j(-td <br />6,po EKv)1r On httstlz <br />'1/ <br />l ADDRESS 400 �• W'I Iffy) <br />Q /V,' <br />�iltQV�S �IUCI p0 / PHONEI '�1��• ��� <br />SUB CONTRACTOR r Q I VQ {, 1V <br />\/ Dr'1 L 1 LL Q <br />ADDRESS <br />UC+E 6 5$ 7 6 p<,E 9 <br />TYPE OF WELL/PUMP: 43NEW WELL <br />❑ REPLACEMENT WELL <br />�` MONITORING WELL/ 6 111 V <br />❑ OTHER <br />❑ INSTALLATION <br />❑ WELL SYSTEM REPAIR <br />❑ CROSS -CONNECT REPAIR <br />❑ VAPOR EXTRACTION WELL f J <br />❑ New ❑ Repel/ <br />H.P. <br />DEPTH PUMP SET FT. <br />FIRST WATER LEVEL p�• <br />(TYPE OF PUMPI <br />❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL 4 ❑ SOIL BORING g� <br />❑ DESTRUCTION: <br />INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br />❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION to <br />rr DIA. OF CONDUCTOR CASING O <br />❑ DOMES1IC/PRIVATE Rid GRAVEL PACK/SIZE # TYPE OF CASINO/STEELIPVC c1' V DIA. OF WELL CASING 1 0(--") <br />^ <br />ElPUSLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL 7 SPECIFICATION SL� •1 SIO R (C-- <br />❑IRRIGATION/AG 11OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME F0111 16 IL-1 E <br />tpa� MONITORING �• 1 GROUT SEAL PUMPED: ❑ Yoo [AN. CONCRETE PEDESTAL BY DRILLER: ❑ Yeo (MN. S A <br />APPROX. DEPTH S J LOCKING CHESTER BOX/STOVE PIPE S <br />PROPOSED CON{TRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER_ CABLE OTHER <br />1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND <br />REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br />THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{ COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB -CONTRACTING SIGNATURE CERTIFIES <br />THE FOLLOWING: • 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{ COMPENSATION LAWS OF <br />CALIFORNIA.' THE APPLICANT MUG CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION{ AT 12001409-3423. COMPLETE DRAWINO AT LOWER AREA PROVIDED. <br />SlOned X. 74C" /Vl�-/�t,(/' TI11e S P N i0 Y Oq ff <br />r Dote <br />PLOT PMN IDrow to Soolel SoHo • to <br />1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br />2. OUTLINE OF THE PROPERTY, 01VING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br />3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br />STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br />Applloollon Aooeptod <br />Orout Ir poallon <br />beNnrellon In.p—ti.. Bv_ <br />DEPARTMENT USE ONLY <br />Inopeotlen <br />1Z, <br />G' <br />Date "' Aroo <br />Dote <br />ACCOUNTING ONLY: <br />AIDII <br />FAC,I <br />PE CODES <br />FEE INFO <br />AMOUNT REMITTED CHECKff/CASH <br />RECEIVED BY DATE: PERMIT/SERVICE REQUEST NUMBER <br />INVOICE <br />( <br />f� <br />Pub. Health Serv. - Enviro. 173 (1/97) <br />