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a APPLICATION FOR WELL/PUMP PERMIT RECEINE SART JOAQUIN COUNTY PUBLIC HEALTH SERVICES AUG 0 51998 ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 SAN JOAQigN tX)UNW 209 468-3420 PU81-C HEALTH S>:'MCES ENVIRONhIENTAL HEALTH DIRRSION 1300-REFUIIDABLE PERMIT EXPIRES 1 YEAn FROE1 DATE ISSUED (Compbto lel TrlaDxate) APPLICATION IS"ERE BY MADE TO THE SAN JOADUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORT(DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHA E�115.3AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. I DAu 17 JOB ADDRESS/OR APNf yt-t 1��/, A ,�g�/1 / 0 _CIT2,44 ' Lo 1',,n1 // -��-y PARCE 819 e —'O -30 OWNER'S NAME �L �J= I�L/��1 ADDRESS /4�Wti�16:5T I. �t 7 iL Il•�eIPHO�NE f CONTRACTORPR r" �s►Q i7�N.A I-��I�7� ADDRESS _ _91 JA� A(/p�A clr PHONE f, 9IRT CONTRACTOR ADDRESS UC7 _ _ - PHONE f TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONrTORING WELL f ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CR098•CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑NOW❑Repek H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMPI ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL f �901L BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION OPECIFICATION91 ^ 11 A ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION G DIA.OF CONDUCTOR CASINO D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVCMt) DIA.OF WELL CASINO D ❑ PUBUC/MUNICIPAL �VEN DEPTH OF GROUT SEAL/jL {L SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY 'q-7y/1�,///l. GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑VM 11 Ne CONCRETE PEDESTAL BY DRILLER:❑Yr ❑Ne 5 APPROX.DEPTH L�7 LOCKING CHESTER BO,XISTOVE PIPE /� S PROPOSED CONOTRUCTION/016WNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Toso zoop E. 1"MBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORT(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 AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PEROONO SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWINGS 'I CERTIFY T IN IE PE )MANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1$HALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CAIJFORNIA.' T APPLICANT V C 2I IN ADVANCE FOR ALL REQIlS1ED INSPECT10N0 AT(200)ADO-8421. COMPLETE DRAWING AT LOWER AREA PROVIDED. BlOrbd X / Title Data 7 T PLAN IDrwv to Social Sade 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PIgPOSED S. LOCATION OF WELLS Wrn"N RADIVB OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAE OUCH AB PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. t DEPARTMENT USE ONLY Application Accepted Byf1""`� Date Arco Grout Impaction By Data Pump Inspection By Data Deatnatlen Impaction 8y Data Ceinmenta: .J �� a ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHEC # ASH RECEIVED BY D TE PO MIT16ERVICE REQUEST NUMBER INVOICE Pub Health Serv.-Enviro.173(1/97)