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APPLICATION FOR WELQPUMP PES T SAN JOAQUIN COUNTY PUBLIC HEALTH 51-AVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICBmpleta In Triplkat6► APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOTF�JJ-f(T TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNI 1 T (' ,,,)V� L� Jj �\--+ � ^ CITY I PARCEL SIZE/A I /43 -/L/-25 OWNER'S NAMES/L�T�- R r'�Si�]c�h ADOR:88/-//[2 •'/..J-`Lr_77(-In^ 'JIU !Q P ONE# 69033,3 --.,T-7 CONTRACTORL,��✓ ��-II ,L/lL AODnES8��7G�/LO�7C�--t I `�/ PHONE/7-0/ �Z-7E77 RUR CONTRACTOR ADDRESS LICO PHONE/ _TYPE OF WELLTUMP• ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL IF ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J ❑New 11Repr.1, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PVMPI / ❑ OUT-OF-SERVICE WELL ❑ GEOF41YSICAL WELL 0 ❑ SOIL BORINO g y 54&fl-^,a /0 71- ale, "�.L -P I U INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL OPEN O�PEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D S ❑ DOMESTIC/T`RIVATE ►d-GRAVEL PACKI8IZE TYPE OF CASINO/ EE VC /',I e- 'I V MA.OF WELL CASING D ❑ UC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL \ SPECIFICATION IRRIGATION/AG ❑OTHEn GROUT SEAL INSTALLED BY i�'t'.°ir GROUT BRAND NAME _Aa_ E ❑ MONITORING - ❑GROUT SEAL PUMPED:'[ Ne CONCRETE PEDESTAL BY DRILLER:11Y• ❑No S APPROX.DEPTH L�n1"may...+i1 ' LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY 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 RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFOnMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIAN.' TJ�/E.A,pPUCANT/M{U`ST CALL 24 NOVAS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 122001 468-3422. COMPLETE DRAWING AT LOWER AREA 775-/z- PLOT 'ROVID/E/qJ( 8lpned X t6 L[�^f�M-,k wo;t TItle (g�O Cf) J� Det. 7! 'S/z- PLOT PLAN ID,"to Sahel Boels 'to 1. NAMES OF STRFETS OR ROADS NEAREST TO On BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROP06ED Z. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. 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 On ADJOINING PROPERTY. I I / DEPARTMENT USE ONLY oo APP11-11'.Aeeectod Owe'� D • / v Ar � �� Groin I-P-11en By Det. P—p Impoetton By /)7 Ogle ' D.»In�etlenMneetlon Byl DO. V Co—O./�/ / ACCOUNTINO ONLY: AID,F TAC# PE CODES FEE INFO AMOUNT REMITTED CHECK//CA6H RECEIVED BY DATE PERMIT/6ERVICE REQUEST NUMBER INVOICE 35 selti� ? (67W Pub.Health Serv.-Enviro.173(1/97)