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APPLICATION FOR WELL/PUMP PERA SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 1 �� NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDl'7'�3�I ^ l (Complete In TPIpReatel APPLICATION IS HEM BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITII BAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER /{•9-1115.3 A1,l D WE STANOA e F SAN JOAQUIN COUNTY(�PUBUC HEALTH SERVICER,ENVIRONMENTAL HEALTH DIVISION. Z'•�� JOB ADDRESSIOR.A1�PNJ I(, IT}]]-) 1'� 1L In I�CI.I I I ll�.lr•YLJ CITY—TO PARCEL BIZE/APNI OWNER'S NAME rI TZ�/fr?4'L K- TT6 MES ADDRESS ILL � IU T Y PN' I_�J� (`(��3F� /f5 CONTRACTOR��/1A�l CA C1LYL_ L�JI.C-� I ADORE6 I�I 7,� UClO/ONE�I /`�-13Y7 SUB CONTRACTOfl—T1 JAA /�C�LO�R�,TI(i�\� AODRE81 6S E/�14fi//M Q''.i'7��Q§'Jpy uc,5,2268 PVror�e� /w- TYPE OF WELUPUMP: WELL ❑ REPLACEMENT WELL �NITORING WELL I1,(,T❑ OTHER !!!❑ INSTALLATION ❑ WELL SYSTEM REPAIR JJJJJ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLM_ J ❑N.❑Fe .I, H.P. DEPT"NMP SET_FT. FIRST WATER LEVEL O (TYPE OF MMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL, ❑ SOIL BORING S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSH IVJL A ❑ INDUSTRIAL 1:1 OPEN BOTTOM DIA.OF WELLEXCAVATION L DIA.OF CONDUCTOR CASING A- D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE-,IIz TYPE OF CASINGISTEEI/PVC DIA.OF WELL CASINO 2 ,H /_11 ,( O 11PUBUCWUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL ,L S SPECIFICATION <�:JA 40 R �❑ IRRIGATION/A0 ❑OTHER GROUT REAL INSTALLED BV I\I GROW BRAND NAME WA- E \P(M.ONITONNO GROUT SEAL PUMPED: 11Y. [IN. CONCRETE PEDEBTAL BY DRLLEq:❑Vu [IN. S V — I APPROX.DEPTH D LOCKING CHESTER BO PPE S PROPOSED CONSTRUCTIORUDIBLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.ANO RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IB ISSUFA 1 BIIALL NOT EM OV PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOIMNG: 1 4ERTIFY T IAT IN HIE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS IBBUED,I$HALL EMPLOY PERSONS SUBJECT TO WOWMAN'S EOMFENSATION LAWS OF CALIFORNIA.• i A N IUST ALL 311gMe IN ADVANCE Foq ALL REOURED N TIONS AT MOS/T14011�JA3J. COMPLETE DRAWING AT LOWER AREA PK! IDE . SI'—I% TI$. 172o PLOT PUN EM.I.$e.ia1 S<.I. •to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 3. OUTLINE OF THE POPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SE VAOE DIBNSAL SYSTEMS. G. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROFOBED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. LAlu I DEPARTMENT USE ONLY APRlle.11en Aee«led By �/I V' _Mu �S Dele O,em Imp«Gen By 1✓ Dele Pune In.p«filen By ONa bminmllen Imo«Ileo By Do. Dnmme„1.:• - � an-l�,Q .mac-cw-a-� - ��,�� eP cz,..-�' rQo�,LoH�,� Q ACCOUNTING ONLY: AID# FACT PE COD" FEE INFO AMOUNT REMITTED C EC ASN RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBEN INVOICE 01 L 0 Pub.Health Sew.-Enviro.173(1/97)