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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> (209) 468-3420 <br /> MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplah III TFiplkstal <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1(115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMSION. <br /> JOB AODRESWOR <br /> t I/ f CRY &t ��v PARCEL SIZE/AFNI <br /> AIyyP//HS n � <br /> OWNER'S NAME ^l3'Lc- -cryCSB ��L� PHONE! t4 <br /> 3� <br /> CONTRACTOR "'�'�-�I -'L-��T�'7r� C U AODF1E88 (-4L L- S. UC/ IL Z 3 7 3 PHONE <br /> SUB CONTRACTOR ADDRESS UC! PHONE <br /> TYPE OF WELL/PUMP-. Cl NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER <br /> Cl INSTALLATION ❑ WELL SYSTEM REPAIR Cl CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J <br /> .l-T— ❑New❑Repdr N.P. "�']� DEPTH PUMP SETJ�FT. FIRST WATER LEVEL <br /> (TYPE OF PVMPI <br /> ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL.I Cl BOIL BORING <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D� <br /> ❑ DOMESTK:R'RIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASINO OGI <br /> Cl PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R <br /> ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Vr [IN. CONCRETE PEDESTAL BV DRILLER:❑Yr ❑Ne S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S <br /> l <br /> PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> 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 <br /> THIS PERMIT IS ISSUED,1 8HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SU"ONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.-,!f •- 1/E(J.^/PPUC ANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION*AT(2061 4pLE <br /> 4M22. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Blvwi X � IY C7-*.Z L_ Tltf. //'L-�1�•1 _ Dete li `.L �,✓ <br /> 7 <br /> PLOT PLAN 871ew to 8aelel S-1- 'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PLOPERTY. 1. LOCATION Of HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY.OIVMK)DMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE D48POM SYSTEMS. <br /> ]. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RAMS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,MICLUOING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> PAYflIf ENSR. rElVEr' <br /> JUN 301998 <br /> 5AN:JOAWIN COUN#V <br /> PVBUC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION: <br /> r <br /> It <br /> I ...... . .............. I <br /> DEPARTMENT USE ONLY / <br />