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' -Q4PPLICATION FOR WELL/PUMP PERM" y ` SQAQUIN COUNTY PUBLIC HEALTH SEES ENVIRONMENTAL HEALTH DIVISION ` 304 EAST WEBER AVENUE, STOCKTON, CA 95202:; (209) 46$-3420 r � f,�- 71 NOW-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE'ISSUER'.r (CEmplete ID Tr1plieatal f APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLImljIbN�;,PAOE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE. �CHAPTER +8-1 115.3 AND THE STANDARD8 OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL, EALTH DIVISION. JOB ADDRES$/OR APNO r l%%+k t n CITY - PARCEL 8IZEJAPN/ OWNER'S NAMErL�t�, ADDRESS [�-U - T PHONE t�Z 't4Q)a eelT4w.r75A �9 41 .l: 17�n AA e 7A- ADDRESScl i b LA/V-9-mo �Jj1��12Cf ((�sc.�S PFIDNE N L�Cj 3�OT t 6oNTMCTOR - ADDRESS Z L u"" mo 14 Z 3Q 0 PHONE fo TYPE OF WELLIPUMP; ❑ NEW WELL ❑ REPLACEMENT WELL `❑ MONITORING WELL N ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 0 J ❑New❑Repair H.P. DEPTH PUMP SET 1'FT. FIRST WATER LEVEL O ITYPE OF PUMPI 3 ❑ OUmOPiSERVICE WELL ❑ GEOPHYSICAL WELL N �I, SOIL BORING ' g ❑DESTRUCTION: INTENDED USF TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL CI OPEN BOTTOM OTA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO p ❑ DOMESTICR'RIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINOISTEELIPVC CIA.OF WELL CASINO p ❑ PUIILICIMUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME F ❑ MONITORING GROUT SEAL PUMPEO:vY- ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yea [:]No S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE g PROPOSED CONSTAUCTIONAMELINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER ec-, I HEREBY CERTIFY THAT t 14AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAOUIN COUNTY ORDINANCES,SPATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE POLLOWINO:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1$HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRINO OR BUR-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING; 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'/COMPENSATION LAWS OF CALIFORNIA.2THE APPLICANT MUST CALL 24 HD ITE IN ADVANCE FOR ALL REQUIRED IINNSSPE�CITOONS�ATT11"01 4004422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Stoned X — t- T Tltta ,�i.Sl� 1�' M�G J`„,..... Dale PLOT PLAN(Claw to Bede!Scale '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 PROPERTY,OMNI!DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYBTEMB. 3. DIMENSIONED OUTtfNF.S AND LOCATION OF ALL EXISTING AND PROPOSED - Be 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. s -;Former Gasaiine Cheaper Station $1( Station "' i... 'a ;... .. ...... . Grantiine Road -_ ------------------------------ Am— ., �oalanman wren!�! une.aglauno Elecure x.rn\} ��nnrynalaae a 501±saavaPOn 'enl —"'—' � — .1�scavallcn fib 4 'i � ' : - I�T-I ,-5 I a Passer r C c'eeze _ acol>'Imare I � t-rah/] �f� ! �racy Auto Stereo AA 1 -- �smovw c^i'� — ?•coenv Curer r- e y►a.Yr•,y.-f _ try�rw....,,u. -DEPARTMENT.USE ONLY, . Applleatlon Accepted By e .. -�....-,- Dere `! C!� Atom- C>,7 c Grout Impeellen By Date Pnnp Impeetlon BY '7Dolts ctl 0—In.11cn Inapeen BY ljo`A Data dit SFd ACCOUNTING ONLY; AID,T FAC! .�jL GYG4� i. PE CODES FEE INFO AMOUNT REMITTED HEC IfCASH RECEIVED BY DATE PERMITISERVICE REOUMT,NUmmEn INVOICE sR002/7,� Pub.Heafth Serv.-EnvirD.173(1197) =