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�{ APPLICATION FOR WELLIPLIMP PERMIT / 6'Q 5c5d _ } SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION UUU� Z�� 53 1q P 0 BOX 388, 446 N. SAN JOAQUIN ST, STOCKTON, CA 95201388 �� D20 1 Izosl 46e-3420 Of �j— ?.Sc�- NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED G (Complete in TrgDertn) U D APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPUCA ION I6 MA IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JO IN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/SR APN, 9-12-02 CTry PARCEL SRE/APN, AI S- 9fk�fr-S OWNER'SNAME ncle C) Tsa Opo losJRnrElPn Banc DDRE66915 17th Street,Sac, PHONE, CONTRACTOR Purviance Drillers, Inc. ADORE66 P.o.Box 64,Lindect, 377923PHONE,887-3554 SURCOWRACTOR n/a ADDRESS LIC, PHONE, TYPE OF WELLMUMP. Q NEW WELL ❑ REPLACEMENT WELL ❑ MONrTOPoNG WELL, ❑ OTHER ❑'7 INSTALLATION Cl WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL, J ]rh Q New❑R.P.4 H P. 1 0 0 DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑GEOPHYSICAL WELL I ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ®OPEN BOTTOM DIA,OF WELL EXCAVATION_ 22" DIA.OF CONDUCTOR CASING n/a D ❑DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEVPVC steel DIA.OF WELL CASING 1 6 OD D 1❑1-lI PUBUCIMUN1CIPAL ❑DRIVEN DEPTH OF GROUT SEAL 300 SPECIFICATION •2 5 O R 21 IRRIGATION/AG 13 OTHER GROUT SEAL INSTALLED BY PDI GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED. ®Ys ❑No CONCRETE PEDESTAL BY 1)FULLER:❑Y— ❑Na 5 APPROX.DEPTH 650 1 LOCKING CHESTER BOXISTOVE RPE PROPOSED CONSTRUCTIONMAILUNO METHOD: MUD ROTARY x AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULE&AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WO WC FOR WHICH THIS PERMIT IS ISSUED,1&HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.•CONTRACTOR'S HIRING OR 6VOCONTRACTV40 SIGNATURE CERTIFIE THE FOLLOWING: 'I CERT I IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALFIA.' T PU T Ue ALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1209)4403422. COMPLETE DRAWING AT LOWER AREA PROVIDED. .I..J TItI Corporate Secretary Dete 9/23/96 PLOT PLAN Ml—to Soalel S— •Ip 1- NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ]. DIMENSIONED OUTUNF6 AND LOCATION OF ALL EXISTING AND PROPOSED 6. 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. N .. ..... PAY'MEN'T JI EP 23 � 7996 PIIBLIC`iEk?H bERViC;E, L,Yylc^ Oytez+x �'� r�vtRL Ir�I LTri H`r_Fi 1 v - .... r� DEPARTMENT USE ONLY ApPI-11 n Accepted BY - - - __ — -- -/-2 A... 1 L 7 G—Iropxtlon BY Datad�'� AumP Ine Ion B / % pet Y _ De[e7 D�bv vn Inapectlon BY _ One Commety ACCOUNTING ONIY: A. FAC, PE CODES FEE INFO AMOUNT REMITTED CHEC ISCASH RECD VED BY DZ17E - _ PBiMITIb EAVICE R FB ETI INVOICE 3 L O D �3d - � 0 Oa Q130 o ' SR.O --- a 8