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APPLICATION FOR WELL/PUMP PE*f JOAQUIN COUNTY PUBLIC HEALTHVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DECCRIBEO.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNI L✓L,:IC kL,� S'-�� L f � �- k CITY 4, �} PARCEL SIZE/APN/ OWNER'S NAME_ q f7 ADDRESS I (Lll �t - �� r f '1r� fJ`.� CIT- PHONE+r CONTRACTOR f-11 � - 3 _ WJ-:,'ilW-�•� Y✓^ () C.U �,h 11 r L11L. ADORES 8 S)L� I��t� (�•X rc.;, L1C/ �JPHONE/��v SUB CONTRACTOR_.. c,lc.o q ADDRESS. n S I�dt 51 0 — I �,.� S�- UC/ PHONE I e y o TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL PfMONITORING WELLI K OTHER t --7 > ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR VAPOR EXTRACTION WELL I V CW ❑ (TYPE OF PUMP) New 11Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL S ❑ SOIL BORING 9 ❑DESTRUCTION: INTENDED USF TYPE OF WELL CONSTRUCTION SPECIFICATION$ A ❑ INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATIONy DIA.OF CONDUCTOR CASING IV�rt D ❑ DOMESTIC/PRIVATE 12 GRAVEL PACK/SIZE f SL..wl TYPE OF CASINO/STEEVPVC P bi,,-, s(Ll _ U DIA.OF WELL CASING z 1. D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL l SPECIFICATION Ak—t C.w. - //kr�•,� Gi�...T R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAMEn _/ - LI_ E _--I E MONITORING GROUT SEAL PUMPED: [IY-VNo CONCRETE PEDESTAL BY DRILLER:KI Y« [IN. S i `, APPROX.DEPTH �; - 1 S LOCKING CHESTER BOX/STOVE PIPE 57,.14 a�-- S PROPOSED CON$TRUCTION/DAILLING METHOD: MUD ROTARY AIR ROTARY_AUGER CABLE OTHER 1 HVIFRY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH 71416 PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIr1E8 THE POLL OWII.,CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT I8 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.' APPUC ANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION$AT 1208)4$$-342?. COMPLETE DRAWING AT LOWER AREA PROVIDED. z:j — V,,�V%4 v�L'" Slgrud X r.v I~v..t Tltle 1.:.`}t...� ) t /Y ea9:t��.-w.-.�-. Ian wr., .-> IC7 iI. Date PLOT PLAN IDraw to Scolel Scale 'to 1. NAMES OF STREETS On ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROP06Eb 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY rT. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY On ADJOINING PROPERTY. d DEPARTMENT USE ONLY Appllcatlon Accepted By ,. ./� / M.'/C' l�� Date _7 ._. rl- Arsa�C7 � v Grout Impeetlon By Date Pump Impeetlen By Data bcatne;tlen Impxtlon By Date Cemmorrta: 5- ACCOUNTING ACCOUNTING ONLY: AID# FAC/ r"e^ PE CODES FEE INFO AMOUNT REMITTED PIECKIJCASH RECEIVED By DATE PERMIT/SERVICE REQUEST NUMBER INVOICE A, Pub.Health Serv.-Enviro.173(1/97)