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APPLICATION FOR WELL/PUMP PERF. ` SAR'JOAQUIN COUNTY PUBLIC HEALTH SEWICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Ctmpl{t{in TrlpRentt► APPLICATION IS 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 WRH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTYLPUBLIC HEALTH SERVICES,ENVRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNO l.]_`o W. �L(� p� �� CIT�fLL��S-! 'DIL ->-1`TNY1I"M / /� PARCEL MZE/APNI Q OWNER'S NAME ` ADDRESS I I T D C,U` �y i I►i 1 4,f- /L' 1 'y� PHONE/ [ So CONTRACTOR r/ q ADDRESS�L (/1 S4 E S�HC'i L` f may- PHONE I S3,F—gL�50 SUS CONTRACTOR O U U 1 •L AOOREB/ 5U e -1 Oa5(e `-�- ,3 TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL A ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r (TYPE OF PUMP) ❑New❑Repelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT-OF-BERVICE WELL ❑ GEOPHYSICAL WELL s SOIL BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS / A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O ❑ DOMESTICIMIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEUPVC i DIA.OF WELL CASINO O ❑ PURUC/MUNICtPAL ❑UmVEN !l, DEPTH OF GROUT SEAL — SPECIFICATION R ❑ IRRIGATION/AO 11 OTHER GROUT SEAL INSTALLED V CnLLT7 (A� ` GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED:D(Yee . IN. CONCRETE PEDESTAL BY DRILLER:❑Y_ ON. S APPROX.DEPTH LOCKING CHESTER BOXRTTOVE PIPE S PROPOSED CON{TRUCTIONR3RIlUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HERESY CERTIFY THAT t 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 LK:ENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOV^O:'1 CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 BIIALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPMOATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT to ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPFN{ATION UWB OF CALIFORNIA.' THE APPUCANT MU CALL 24 URO IN ADVANCE FOR ALL REQUIRED IINNt�PEJC_TINONt AT 12001184422. COMPLETE DRAWING AT LOWER AREA PROVIDED. 9 Maned X 71da Det. L PLOT PLAN IOre v to So lel SeNe •M 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 7. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OVTLWFS AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WTTHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. .. .y .. :....... ....... ..? ..,......'...........,j......i .. .. ... . - _. . �I JIj��/- _D Xn DEPARTMENT USE ONLY (} ApPSaetbn Attempted By`r'�,�11ae \ DN. ?/2 12 Arr LU�• 0,.,d Inep—d—BY Date Rmp Impeetlen By ON. D.+evtnUen Lwpeetbn By Date cemmem.: ✓ -d�.�/1�c1_ tL/pt S ACCOUNTING ONLY: AID/ FAG PE CODES FEE INFO AMOUNT REMITTED CHECKIFMASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 7ill%' EEL Pub.Health Serv.-Enviro.173(1/97)