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I r*'PLICATION FOR WELLIPUMP PERMIT . Sku.JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX W8, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 488.3420 RON•REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Tripficrts) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED,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 ADDRESSOR APN, 11 811 Suri Rd. CITY Stockton PARCEL SIZEIAPN# OWNER'S NAME James Smith ADDRESS 11811 Suri Rd, Stockton PIONEx cokTRAc7oR Purviance Drillers INc. ADDRESSPOBoX 64 Linden LIc, 377923 PHONE, 887-3554 SUS CONTRACTOR n/a ADDRESS LIC, PHONE, TYPE OF WELInMP; ❑ NEIN WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL, ❑ OTHER - © INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR _ ❑ VAPOR EXTRACTION WELL, s ubmer s i b3 Qw❑Repair H.P. 1 5 HP DEPTH PUMP SET1 8 O FT. FIRST WATER LEVEL d- (TYPE OF PIMP) _ ❑,OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL, ❑ 60R BORING R ❑DESTRUCTION: - Y INTENDED USE TYWELL PE OF WL CONSTRUCTION SPECIFICATIONS -7 q r ❑ INDUSTRIAL - 0 OPEN BOTTOM DIA.OF WELL EXCAVATION__ 14 3/4 'DIA.OF CONDUCTOR CASINO_ n/a D_ ❑ 0048I10MRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELR'VC steel T DIA.OF WELL CASINO 8 5/8 D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 240' SPECIFICATION . 156 _ R ;7 2 IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY PDI GROUT BRAND NAME_ Ur:1—tJE ❑ MONITORING - GROUT SEAL PUMPED: MY. ❑No APPROX.DEPTH 350 y� CoryG E PEDESTAL BY DRILLER:[I ❑No S LOCKING CHESTER DOXISTOVE RPE B PROPOSED CONSTRUCTIONIMLLINO METHOD: MUD ROTARY X AIR ROTARY AUGER CABLE OTHER HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL 13E 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 WORIK FOR WHICH THIS PERMIT FS ISSUED,i SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMANA COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTWO SIGNATURE CERTIFIES THE FOLL 'I CERTIFY THAT I HETPERFORMANCE.O.F THE WORK FOR WHICHTHIS PERMIT-18-ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALLED NIA.' THE CANT MUi ALL, HOURS IN ADVANCE FOR ALL REQUIRED FNRPECT}ONS AT 1200)460-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. 9l0ned Title Corporate Secretary D,te 3/3/97 PLOT PLAN(Draw to Scale)Scale 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2, OUTLINE OF 714E PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 7- DIMENSIONED OUTLINES 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. ..... - ... ..: .. .. --4E Q %4 D� 400 F a. ..' -. ... 4 -. 7.. r.:?-tea ."•r:• - 4111} S --- I L I DEPARTMENTUSE ONLY I J rtil' I it !- �• 4PPII0a11an Accepted By c► -., ,- --�-y�.-• Date Area L•'-� UP I irput Intpocllon BY Date Pump Inspection By Date y7 I ' )eetructlan Inspoc0on By - Date :ommentr. ACCOUNTIN0 ONLY: AID# FAC, -` -'?=INFO AMOUNT REMITTED ECK !CASH RECEIVED 13Y DATE PERMITIS1 VICE REQUEST NUMBER INVOICE CO I J �