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APPLICATION FOR WELL/PUMP PERMIT SAI �AOUIN COUNTY PUBLIC HEALTH SE CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IC°InpNu IR Tr(pPiesb) APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNI 15- W w,AQ A s+o,T CRy I I pQy,,1 A /� PARCEL SIZE/ARJI OWNER'S NAME NS I � _ r Wa Gkk- ADDRESS n-S L-�I ICI�IJ�'1 PIONEI .yy, COMMCTOR SwGR+�A ( \N0 �� CoJ�p 012!'WC�✓1 ADDRESS I�ZJ,�c` vlwy��141Ur. UCP S�//Q�)B OpI PHONE SZo9 sT(�!' SUS CONTRACTOR RILL\ EIA\/\roNty l�,.k•I ADDRESS�J9°I S(A2v�IS hLe.e.- UCP bD^S CJ S ],C}c/ 3L',]S C7 PHONE TYPE OF WELUMMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL R d OTHER A t9y INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR 0 VAPOR EXTRACTION WELL/ J ❑New 0 Rep.I, H.P. DEPTH PUMP SE7_FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) �y 0 OUT-OF-SERICE WELL ❑GEOPHYSICAL WELLS SOIL BORING Z' 30 1 B []DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUC71ON SPECIFICATIONS / A O INDUSTRIAL 0 OPEN BOTTOM DIA.OF WELL EXCAVATION ..1�y�^ DIA.OF CONDUCTOR CASING ��/�1 A 0 0 DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE TYPE OF CASINO/STEELIPVC A) V* DIA.OF WELL CASINO AAI I A D 0 PUBUC/MUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL 30 / /.�� SPECIFICATION nN�✓'L 4 R e /c0 IRRIGATION/AO 19 OTHER GROUT SEAL INSTALLED BY r\N�.I In GROUT BRAND NAME V W�LU•+� 4 Ci E IN MON(TORING 1�� GROUT SEAL PUMPED:0 Y.. L9 N. CONCRETE PEDESTAL BY DRILLER:0 Yr C1Ne S APPROX.DEPTH 30 'Y� LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONSTRUCTIONMRILUNG METHOD:MUD ROTARY AIR FIOTARV AUGER CABLE OTHER 1 HEREBY CERTIFY THAT 1 HAVE PREPARED TMG APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WIT"SAN JOAQUIN COUNrY ORDINANCES.STATE LAWS,AND RULES ANO REOULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'/COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRNG OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED II'N(S�PECTION@ AT 120S1400J 27.COMPLETE DRAWING AT LOWER AREA PROVIDED. (, SI—d X CW\/\/�-- L.�.I TIS. I�A- (� {P L-'YL4`er�� DO. 1'123 ( z PLOT PLAN(O—tp SoN.I S-1, `"t, 1.NAMES of BTnEETB OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DIS SAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY,GRANO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.LOCATION OF WELLS WITHIN MONFIFTY FT. OF ONE HUNDRED FIFTFT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. LU S G Gwo Q cf) zz Ld W� [if W x as LO 00 s o m O O a z= w r o u 'd o " w 4 60} ,.. AIM3AW 1.... 1 —.301S n o w I ° a I 3f1N3nV 1Sf1oOl .................... D17MTMOIT USE ONLY Appllc.tbn Acvap[eM S��\//��"�7�1 D.le �Il � G ArN Grout Imps,...By D.t. Pu p I-pevtbn By Do. Omtnrelbn ImPection BY Do. C.--.:_Aik�b)nnk aY`y,�,uNpi SS Ifu pas /f-im ACCO UNTINO ONLY: AID/ FAC/ PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE PER MITISEAICE REQUEST NUMBER INVOICE 122 ll �.�i' (9 19 I -K' �. L1 Pub.Health Serv.-Enviro.173(1/97)