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&PPLICATION FOR WELL/PUMP PERN& SA JAQUIN COUNTY PUBLIC HEALTH S L. CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 459-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Comokt4 In TrinikstE) APPLICATION IS ITEM BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDNR INSTALL THE WOW DESCRIBED.THIS APPICATION IS MADE IN COMMIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 81115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION, -+ JOB ADDRESSIOR AM# 441 W CST CUM.-LF2. W A q Cm 's-yo C✓-Curl CA PARCEL SIZVAMS OWNER'6NAME DON aooemo2 . ti-1110 5 .✓ J a.o ADDZa9 - 4L4 5180 RESS A AMJ F c 45336 PHONEI `,1 1pd p'FI 7c+7374 43ae• CONTRACTOR VYCOIX.;A211 L121µ wI(' ADORFA906V 336 12404 LSU CA UCJ '�(QQ-ri PHONED SUBCONTRACTOR ADDRESS _UCL PHONE TYPE OF WELI/PUMP: NEW WELL ❑ REPLACEMENT WELL xMONR AING WELL I h C ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I i RVPE OF PIIMPI ❑New❑Reeeir N.P. DEPTH PUMP SET PT. FIRST WATER LEVEL G ❑ OUT-CF-SERVICE WELL ❑ GEOPHYSICAL WELL A ❑ SOIL BORING S ❑DESTRUCTION: INTENDED USE TYPE OF WELLCONSTRUCTION OPECIFICATION6 o B I NCy sloce ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION I S DIA.OF CONDUCTOR CASINO_'. p ❑ DOMESTIC/PIUVATE P(GRAVEL PACK/SIZE .3 SAAR TYPE OF CASINGIRTEEL/0V Sw 40 DIA.OF WELL CASINO Z-. LNCN O ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL T7 6 Z1 96 I SPECIFICATION SCM LJ A ❑ IRRIOATONIAG ❑OTHER GROUT SEAL INSTALLED BY I� GROUT BRAND NAME C6..J T E .'MONITORING GROUT SEAL PUMPE13:113 Ys ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yn ON. 5 APPROX.DEPTH LOCKING CHESTER 60XI81OVE PIPE S PROPOS"CONSTRUCTIOR DI6WN0 METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER 1 HEREAY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PEANUT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WOLF(FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'TTHIE APPLICANT MUST CALL 34HOURS IN ADVANCE FOB A RFD INSPECTIONS AT 12014000422. COMPETE DRAWING AT LOWER AREA PROVIDED. 61or,en X_!s/� /L-��-�.-.t TI 1._ IY/Ni✓A ej E// D.I. 12 -/0- 1 ? v MOT PUN 0.m Be.I.I ern. m `� 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED Z. OUTLINE OF TILE TIOKRTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED e. LOCATION OF WELLS F ONE HUNDRED FIFTY R. STRUCTURE@ INCLUDING COVERED AREAE SUCH AS PATIOS,DW VEWAYe,AND WALKS. ON THE PROPERTY OR ADJOINING PROPS .... .... ........ . _._...........:....... .... ,^.\ 11� .T� `V V 9"t./ DEPMTMENT USE ONLY ve AnonoRnn AroReM By. �tiTAro � bn � Groot Imn,Nnen By Go. Pump In.Peenen By Dns D,.n,eNlen Imnemlen�B`y p.N ACCOUNTING ONLY: AID# FACT P!COOEA FEE INFO PMOVNT REMITTED CHECKIR:ABN RECEIVED eY DATE PEV.IITISEAVICE REOLROTT NUMBER INVOICE Pub.Health Sew.-Enviro.173(1/97)