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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TFIpDental APPLICATION 19 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 9-111 5.3 AND DTTHE ,,STANDARDS OF SAN JOAQUIN COUNNW PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ,l JOB ADDRESSOR APN/ �32Q (�j �) I�"I t�—0 \ CITY L��/✓Il civ 1 Q PARCEL SIZE/A IV 1 J00 v OWNER'S NAME�P2VY`60 4__JW 1 C�O ADDRESS 3Z� "�• '^ I `�Z3 P 9 — I CONTRACTOR (�JY� rt' ' I( //qS C. O �j'�SQ��r�o 8 1 pl c I I� `lul��l--/1 U I 2� /6 PHONE.? 2—SS SUS CONTRACTOR !V� V I" A' DD S i UC/ 57 2`v / Pf(91 TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J ❑New❑1lepel, H.P. DE PTN PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMPI {(�, I 0 GOUT-OF-SERVICE WELL (,❑ GEOPHYSICAL WELL/ A!$- TOIL BORING (� _v' `-7 B �ESTRUCTI*N: �kc- '[\ _ "I t - - / INTENDED USE L)PE OF WELL CONSTRUCTION SPECIFICATIONS Q!� A ❑ INDUSTRIAL ❑OPEN BOTTOM VIA.OF WELL EXCAVATION -S DIA.OF CONDUCTOR CASINO h" D ❑ DOMESTICR`RIVATE ❑GRAVEL PACK/81ZE TYPE OF CASINO/BTEEL/PVC,( /� IJ DIA.OF WELL CASINO D ❑ PUBLIC/MUNICIPAL �❑l onivEN /� DEPTH OF GROUT SEAL fly 7r 1 (`Lp W\\SPECIFICATION R 1❑ IRRIGAMN/AG .2;THER A--I A./" GROUT SEAL INSTALLED BY hr,� GROUT BRAND NAME_ E IANONITOFUNO(JL-0'' _ , f�7t' GROUT SEAL PUMPED:,�Y— [IN. �I /� CONCRETE PEDESTAL BY DRILLER:❑Ys e 5 APPROX.DEPTH 35 '� � '7�/1 LOCKING CHESTER SOX/STOVE PIPE 'T ZT 5 PROPOSED CONS TRUCTIO N/DPoLUNO METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER I HE'"Y CERTIFY THAT 1 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 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'i CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS BUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWi 1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA THEA C TTM HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION*AT(200140,18-3-423.�,�/�COOMPL�ETE DRAWING AT LOWER AREA MID ED. Sl/nod X Tltle I"�{ \ �`'rc-L ONe LP PLOT PLAN 9),—to 9ee1.1 Boole to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. T. DIMENSIONED OUTLMF*AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. U� _ G -------------- r R r7 � . JUN 219914 BAiu+1kJF15fEr11�lt�I�^�/iUti IOUSUC Hr-A(Tfl OlffIVI(JEb <`lIAONMENTAL.HEALTH 01"Slotj I� DE,rP�TI[vENT USE ONLY Aoplleetlon Aeoepled By "V r�X�` �/ - ' `-'"\ \ DNe �� A— ZGrout Impeetlen By—A Dae mp Inepeetlon BY Dae Dost—len I-`n--4—BY Cemmer.te V c-12 I/ ' �� 0)(—� ( Dotel G (' c� - Ao 4gy 5,1 to , ,z- cid L4-0 ACCOUNTING ONLY: AID/ FAC/ PE CODE* FEE INFO AMOUNT REMITTED CHECK !CASH RECEIVED BY DA E PERMITISERVICE REQUEST NUMBER INVOICE vs Pub '4ealth Sely.-Enviro.173(1/97)