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Com/ r 'G APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468_3420 ORIGINAL NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER (Cempleta M TrfpReale) APPLICATION 19 HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PURL IC HE TH SERVICES,ENVIRONMENTAL HEALTH DMSION, JOB ADDRESSOR APNI /�/'74q Al. T Na�r+f�-/�r1 V�- CITY ]� /� V_ i ,/ j /) / PARCEL SIZFJAPNS Q OWNER'S NAME d J A h dy L- aya '\n�t ADDRESS • ./ u A1,6 o�'x Q '1 0 �L PHONE, 0//� 0 ` CONTRACTOR Aka;f r Gco hV eN t ADDPE 88 �G►OS /V/• YV fyyN {t11 L11�ucl 66 0 PHONE F'�IU��ua� eve CONTRACTOR ADOMS8 LICS PHONE TYPE Of WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL )_14AONITORIN0 WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑New❑Rep.1, N.P. DEPTH PUMP GET FT. FIRST WATER LEVEL O RYPE OF PUMP) ❑ OUT-OF-WRVK:E WELL ❑ GEOPHYSICAL WELL R ❑ SOIL BORING G ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ^/ A A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION INC CIA.OF CONDUCTOR CASINO I'//T p ❑ DOMESTIC/PRIVATE 'GRAVEL PACK/SIZE S aN TYPE OF CASINGMTEELPM Pv L DIA.OF WELL CASING Z- t w( �I/, O\� 11PVSLIC/MUNICIPAL ElRI DRIVEN DEPTH OF GROUT SEAL S N Y 4(,r 1 U E, SPECIFICATION Scf u/T // '�T V 1� ❑ tMOATION/AO ❑OTHER GROUT SEAL INSTALLED BY T.e mi a GROUT BRAND NAME MONITORING ^ S 4 GROUT SEAL PUMPED:W_Y.e ❑No ` 'I CONCRETE PEDESTAL BY ORILLE{T&ee ❑No APPROX.DFPTH ' L..� -^� LOCKING CHESTER BOX/STOVE PIPE 1'e ttt c�'� S� PROPOSED CONSTRUCTON/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER__CABLE OTHER 1 HMSY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE M ACCORDANCE MTN GAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AN REGULATIONS Of THE SAN JOAOUIN COUNTY. NOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT M THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT 18 ISSUED,181/ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFOR MA CONTRACTOR'S HIRING OR GU"ONTRACTMO SIGNATURE CERTIFIER THE FOLLOWING:'10ERTIFY THAT M THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WOAKNIAN'S COMPENSATION LAWS OF CALIFORNIA.'_THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUMED INSKECT10j/"t'j��AT 12001/400-2/23. COMPLETE DRAWING AT LOWER AREA PROVIDED. Bt/ned X ///{/�Lj =l ri Tltlo aI ( I ✓ ��/l G' �) ( f 1 Dote_ PLOT PUN ID—to Bo.1e1 B..I. '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 THE PIOPERTY,O"M DIMENSIONS AND NORTH DIRECTION. EXPANSION Of SEWAGE D48POSAL SYSTEMS. 2. DIMENSIONED OVTLINES 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. �3\ 1�j I� DEPARTMENT USE ONLY AWB-0—Accepted By .,/ r�g�/ / A.y ✓iL/U Grout Impoctlon By .to Pu p lmpe tion By Det. OMlructlon I.wnecllon BY O.te CommdN� 14 r '� ACCOLTNTINO ONLY: AID/ FAC/ PE CODES FEE INFO AMOUNT REMITTED CHECKI/CASH RECEIVED a DATE PETMITISMVICE REGUfst NUMSFR INVOICE 350 IU,(,t1 Puh HAalth RA" _Fnvlrn 171 11/07%