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I APPLICATION FOR WELL/PUMP PERMIT I SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 WOR-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplets In Trlpkatel APPLICATION 19 STERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AN610R INSTALL THE WOW DESCRIBED.TI IIS APPLICATION IS MADE IN COMPLIANCE WRH SAN JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STAlNDARDB OF1 BAN JOAOUIN COUNrY PUBLIC STEALTH SERVICES.ENVIRONMENTAL HEALTH DTVIBION. JRA AODRE99R)R APNI / '}"' •` �[I,`� CITY ' f I PARCEL SIZEIAPNO ��'/ -= ' OWNER'S NAME /r�'' ♦ •y`— PHONE I f)r�'~ - ^� r Vr h f f 4 +�� ' / /: r ADDRESS: ' CONTRACTOR I.. .r' l C '>�' "�{I C ( «r_' Abb14EB8' r'f� I 1 r�C�/,)^r R�) �V f•_^ yUCI "��"r- t'HONE I�l�rr,�G /i'"�1�C�;. BUS CONTRACTOR �'"I.'.,!.r r `1 If:�',S !t ✓l ADDRESS c_ I_,.1-�1 i_In r'r'11Jr -- ucvr.-.-i ,127G:,PHONE TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL E MONITORING WELL/ ❑ OTHER n - ❑ INSTALLATION ❑ WELL SYSTEM REPAIR '❑ C11069-CONNECT REPAIR VAPOR EXTRACTION WELL I J ❑New❑Sepal, H.P. DEPTH PUMP BET: FT, FIRST WATER LEVEL O IFYPE OF PUMPI a �� / ❑ OUT-OF-SERVICE WEtt. ! ❑ Q}EOF'11Y-j61CAL WELL R[} 7 ❑F SOIL Emma 1 1 B 1 il'JOEBTRUC1 1 7N: I�+jlf'» ��i 'I i�, ;�r.,.-t ! I/ ,d`"�.l_ � ''1•�'r�-T r` �I'J"1� f'� '��,/_r 11-j%i.J—I�7 �I�!J'�. I��,I'I�_IL1j/�f f INTENDED USE USE TYPE OF WFJ.L CONSTRUCTION SPECIFICATIONS I _;Ir /-?//,Ir.!''1Id lvr11 �rt�-�r�c�;u�.bcrJ�L1 ❑ INDUSTRIAL ❑OPEN BOTTOM DIA:OF WELL EXCAVATION GIA.OF CONDUCTOR CA IN O ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINQISTEEL/PVC DIA.OF WELL CASINO b ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OFGROUT SEAt SPECIFICATION R l ❑ IIWtOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONtTONNG GROUT REAL PUMPED: ❑Yr ❑Ne CONCRETE PEDEBTAL BY DFVLLER:❑Ya+ ❑Ne S APPROX.DEPTH - LOCKINO CHESTER BOXISTOVE PIPE S PROPOSED COM/TRUCTIONfDAILLINO METHOD: MUD ROTARY FAIR ROTARY AUGER. - CABLE OTHER SV CEFTTIFV THA7 1}SAVE PREPARED THIS APPUCATpN AND CHAT THE WDNC WILL BE DONE IH ACCORDANCE WITH BAN JOAOUIN COUNTY DRDINANCES.STATE LAW B,AND itULEB AHb REQULATIONB OF THE BAN JOAQURN COVNTY, HOMf OWNER OR IJCENBED AOETNT:'S AIDNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF TINE WORK FOR WHIG}{ TInB PERMIT IS ISSUED,1 81TALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION iJ\W8 OF CALIFOFOIIA.' CONTRACTOR'S IttPoNG OR SUSL01TT11ACTM10 81GNATUFIE CERTIFIER THE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,i SHALL EMPLOY PERSONS SUBJECT TO WOROAAN'S COMPENSATION IlAW8•�OF CALIFORNIA.' THE APPUCAFIT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12081 4089422. COMPLETE DRAWING AT LOWER AREA PROVIDED. /7 Signe!x f .: •'irt TRI. l .; /. -C� l ;f,1 f'' .._ Date PLOT PLAN rMaw to SaaHl Beal. : '10 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPFF". - 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOBID _ 2. OUTLINE OF THE PROPERTY,GfVM WMENBIONS AND NORTH DISSECTION. - EXPANSION OF SEWAGE DISPOSAL SYBTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTINO AND PROPOSED S. LOCATION OF WELLS WRTBN RAMS Of ONE 14UNDIND FIFTY FT. . STRUCTURES,IINCLVDINO COVEFIED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. °f ON THE PROPERTY OR ADJOININO PROPERTY. ...f �.n . f . .. .. . E: ... ....: ..: .. :...... i I\ ;DEPARTMENT USE ONLY Apptleallen Aeeepted IT L C C"1.t 1 1I rDal. - —-----— r � t r . r--� � Grout Irnp"llen By Dote Pump lr»peetlen BY Dau OmInre11en Irnpeetlen BY Dale CommerNa; `� aIllI ACCOTING ONLY: AIDE UNFAC/ 4 PE CODES FEE TNFO AMOUNT REMITTED CIIECKIICASH RECEIVED BY DATE PO MITRERVICE REOLFEST NUMIM INVOICE ii c1