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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 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICoelplat4 in TrlpIkat4) 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 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. 1 �7 JOB ADORE93/OR APNf 30 W, ryl,ail'l. c/ CITYD L-0 J; /1/fy7(J C v PAfkC•€L812 APNf Qq%-jq0 -0 OI ENN R'B fIAME G. a-/1 ADDRESS / • D. 60 1 Jp/PI ^IVHTMP�LHONE f9Zs-6W-- U6QS �Ov�S(4,GWAviVi� (�/ y� ' A 3Yt7 G sS r �t�GeL' l e✓- P-\1 a., I1.4c • ADDRESS �✓ UC# PFIONE #916 631-/300 V +w Dr ILiLh q ADDRESS Pot � S/-, ICvZ ✓I� UCf4� FMQNE #A -4-311-2S15 TYPE OF WELL/PUMP:SLY NEW WELL 11REPLACEMENT WELL �.MONrFORINO WELL fmw 11 OTHER FACE INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR / ❑ VAPOR EXTRACTION WELL f ✓ AMOUNT REMITTED CFI /CASH ❑ New ❑ Repan H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O IT YPE OF PUMPS ❑ ❑ B - i OUT -0F -SERVICE WELL GEOPHYSICAL WELL f SOIL BORING R ❑ DESTRUCTION: INTENDED USE ❑ TYPE OF WELL 11 CONSTRUCTION SPECIFICATIONS It S A INDUSTRIAL OPEN OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASINO OA D 11DOMESTICIPRIVATE �1 GRAVEL PACK/SIZE I )5 GRAVEL < TYPE OF CASING/STEEVPVC 5C- -l0 IV v DIA. OF WELL CASING v O 11PUSLIC/MUNICIPAL DEPTH OF GROUT SEAL !i SPECIFICATION L�-�O R ❑ IRRIGATION/AG ❑ OTHER L _ GROUT SEAL INSTALLED BY 'L Vr 4 �✓1 1 �. GROUT BRAND NAME E MONITORING GROUT SEAL PUMPED: M- ❑ No CONCRETE PEDESTAL BY DRILLER: ❑ Yee (IN. S ` APPROX. DEPTH v S �--�� LOCKING CHESTER BOX/STOVE PIPE S S PROPOSED CONETRUCTION/ONLUNO METHOD: MUD ROTARY AIR ROTARY AUGER_ CABLE OTHER I HE9EBY 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 AN 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 THIS PERMIT IB ISSUED, 1914ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR -9 HIRING OR SUB-CONTRACTWO SIGNATURE CERTIFIES THE FOLLOWING: ' 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'T APPUCA T MUST CA 24 HO�M IN ADVA N CE FOR ALL REQUIRED INSPECTI ON SAT (2001400-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X �(// - ` �`'f Title f 1/Y Date /O O / RPLAN AN W—to 9aelsl Boale4_ ' to viNAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. ',,p4 LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. V EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 1A DIMENSIONED OUTLINES AND LOCATION OF ALL EX19TWO AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. FESS STRUCTUREB, INCLUDING COVERED AREAS SUCH AB PATIOS, DRIVEWAYS, AND WALKS. r/ON THE PROPERTY OR AAJOINMG PROPERTY, r� .. '.. .. ;. V vvte.✓' (Jasr f Gt ST'S .. C"6, \L --1 l µw-1 DEPARTMENT USE ONLY Applleatlen Accepted ByDNe Grout Impaction By Date PvnP I-Pectlen By Date Daauuetlen Impmtlon BY Data r•,.,,,,..,,,.r.. /✓L tv. . .'SYS../ ,.I 9�.cam-�•-� ACCOUNTING ONLY: AID# FACE PE CODES FEE INFO AMOUNT REMITTED CFI /CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE Pub Health Serv. - Enviro. 173 (1/97)