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APPLICATION FOR WELLJPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 000-REFUDDADLE PERMIT EXPIRES I YEAR FROU DATE ISSUED (C$Blpbta In Trip1hata) APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT``_TITLE,CHAPTER 9-1115.3 AND THE STANDARD'S OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR AjPNI FQW\\V.d b ,� x $� ..0 --t Sesta- j Cat 1.1 CITY SfiguO aA PARCEL SIZE/APNI '1' CA-C,?-<s OWNER'S NAME V\ at S413 t.' A01 ADDRESS '4ZJ N. !,r�.fl S~� -A ` //�� •7 �,q PHONE R CONTRACTOR U�ey��-1,� /i-'SSC7<+C:. ,j ADDRESS (((t�T y4� (7GC� a "V UC/ �yrCPHONE/ 5�.y/ Z't�+Z�I� SUBCONTRACTOR `S�'� L-U�L%�✓'OIA.fAr>.N. � ADDRESS `9 SNLYt I§ d,l}� UCg <J tpJ PHONE I 42-- 3S Tv TYPE OF WELL/PUMP, ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONtrORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J 11New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D (TYPE OF PUMPI Y.N.UT-0OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I JCS BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL _ CONSTRUCTION SPECIFICATIONS A'/'n A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION (-'A „ DIA.OF CONDUCTOR CASINO },, A(A D ❑ DOMESTIC/PNVATE ❑GRAVEL PACKAIIZE TYPE OF CASINO/STEEL/PVC &T((& DIA.OF WELL CASINO ,q (A D ❑ PUBUC/MUNICIPAL }❑1 DRIVEN DEPTH OF GROUT SEAL �S �1✓{' SPECIFICATION Q I W� R ❑ IRRIGATION/AG -MOTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME &-A400.;4C�L�I E 4 MONITORING GROUT SEAL PUMPED: ❑ Ne 1 CONCRETE PEDESTAL BY DRILLER:❑YeeLNNe 5 APPROX.DEPTH LOCKING CHESTER BOXMTOVE PIPE� /A�•�- S PROPOSED CONOTRUCTTONIMLLING METHROTARY AUGER MUD ROTARY AIR ROTAAUGER CABLE OTHER O T l I HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN 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 WORK FOR WHICH TWO PERMIT 18 ISSUED,1 SHALL NOT EMPLOY PERSONS SU0JECT TO WORKMAN'S COMMENDATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR OUB-CONTRACTINO SIONATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN TILE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." TH2 APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUAED INSPWTIONO AT 120014�CO-/3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. SlOned X �4_�/ .� Title k �A&A-kCl P V A61-0$moi Dais CIO/ I9 PLOT PLAN(Draw to Social Seale 'to 1. NAMES OF STREET$OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DWEN810NE0 OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELL8 WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOO,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. rc __'....... w LL Sr .._ Z Q Q 3 Q g Q Z Z _ d z QK m 00 .. 0 C- O c7 Z J o = —/ baa c w a V w N U w Q a . O xo a V) L)O i t Z V, U a O Y StoUUO V) O a z. V) V) a I p O I O { O J z _ O o 3 I w i 3 0 9 3 z_ o ¢ N O O E F e z 0 v O 0 a - 3 zZ Z W 3 Ld J 91V-69£-b6 ONIMV80 ® i 1 DEPARTMENT USE ONLY Q /1 Application Accepted By �� Date . l A.» T��` Oreut Impaction BY Data Pump Inspection By Data Daatruetlen Impaction BY 1 0 Data Co—sma: ACCOUNTING ONLY: AID/ FACT ME COOED FEE INFO AMOUNT REMITTED CHECK#/CASII R CEI O OY DATE PTRMIT/SERVICE REQUEST NUNO9I INVOICE 0 ( YQ, 00 7-507 C) cl 8Sp Pub Health Serv.-Elwiro.173(1/97)