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APPLICATION FOR WELLIPUMP PERMIT /J " t SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES /{�t�{' ENVIRONMENTAL HEALTH DIVISION c�53 P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 DZO 6/ /^ (209)468.3420 1aD-196- -7 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED tL-) ` '"' (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICA/ION IS MAD IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115 3 AND THE STANDARDS OF SAN JO INCOUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESS/}(R APN# 9-1 2-0 2 an PARCEL sIZErAPN# o�e'/� OWNER'S NAME nqe o Tsa Opo los/RarrlPn Rants DOREss915 17th Street.Sac, PHONE♦ CONTRACTOR Purviance Drillers, Inc. ADDREss P.o.Box 64,Lindeltt# 377923PHONEs887-3554 SUB CONTRACTOR n/a ADDRESS LIC# PHONE 9 TYPE OF WELLIPUMP: 5� NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL I ❑ OTHER ❑I INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL# J Tell r h IY2 Naw❑Rep.k H.P. 1 n n DEPTH PUMP SET_FT. FIRST WATER LEVEL O (TYPE OF POW ❑OUTdFSFRVICE WELL ❑GEOPHYSICAL WELL# ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑INDUSTRIAL 0 OPEN BOTTOM DIA.OF WELL EXCAVATION 2211 DIA,OF CONDUCTOR CASING n/a 0 Jr, ❑DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC steel DIA.OF WELL CASINO 1 6 OD 0 �❑I PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT BEAL 300 1 SPECIFICATION .250 R py IRRIGATIOWAG ❑OTHER GROUT SEAL INSTALLED BY PDI GROUT BRAND NAME t ❑ MONITORING GROUT SEAL PUMPED:Ea Y.. ❑No CONCRETE PEDESTAL BY DRILLER:[IY— ❑No 5 APPROX.DEPTH 6 5 0 1 LOCKING CHESTER BOXISTOVE PIPE PROPOSED CONSTRUCTIONIDNWNG METHOD. MUD ROTARY X AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LJCENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PRMLT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBLONTRACTING SIGNATURE CERTIFIE THE FOLLOWI G: I CERLTI M THE PERFORMANCE OF THE WORK FOR WHICH THIS PRMR IS 185UED,I SHALL EMPLOY PLRtANS 6UBJECT TO W011pAAN•e COMPE11eATION LAWS OF CAU IA.' T PPU T US ALL 24 HOAR&IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(20914440-3423, COMPLETE DRAWING AT LOWER AREA PROVIDED. S;,,,,,R,� .Lin_�.� �.�� TRI. Corporate Secretary D.t. 9/23/96 IL PLOT RAN ID,—to Scala)huh 'to 1. NAMES OF STREETS OR ROADS NEAREST TO DR 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. 3, DIMENSIONED OUTUNFS AND LOCATION OF ALL EXISTING AND PROPOSED 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. PAY'iu ENr 9t.— rs1 _ SEP 23 1996 �0HCJL,1 P; 8L,IC 4fEkL ..,.. . . J DEPARTMENT USE ONLY Appll4t1on Accepted By _ Date Are. a+z / 77 Grout Iropxtlon By Date�0 j�2 f4unP Iropectlon By 1,ateZ2.�7 Daalruclbn I-0—BY Data C.—I.: ACCOUNTING ONLY: Al.. - FAC/ PE CODFB FEE INFO AMO UNT REMITTED CHEC ICASH RECEIVED BY OATS _ PORMITirumCE REOUES 6E INVOICE 3 l 0f F O X36 n o