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APPLICATION FOR WELL/PUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 pOFJ•REFU00ABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Cempbto h TrlaRaotol APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/011 INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8.1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH OrVI . y L/ JOB ADORESS/OR APNI -//!? .j•S . /I�IQ/� � �s� CITY Z�- �o O Z3 �f .!/lo,Kt'��i9--{ C.� nPAIRCEL SIZEIAPNI_//.��;�1t OWNER'S NAME SG 5 D �f v rT AljiyL T. 94 ADDRESS_/"6'. jC •lOp� ter¢/J0.4 L� PHONE CONTRACTOR �.Zcv T'd!cZi Llil ADORES®713 LL! ��D�'N�/uJ K(.'E•'.[IC1173 PHONE I SUO CONTRACTOR ADDRESS LOCI PHONE# TYPE OF WELLIPUMP: NEW WELL ❑ REPLACEMENT WELL MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# 13N.0 R.P k N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL (TYPE OF PUMP) ' O ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL* ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL -- - CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN OOTTOM DIA.OF WELL EXCAVATION l6 DIA.OF CONDUCTOR CASINO ❑ DOMESTICNPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC OIA.OF WELL CASINO O ❑ PUSUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E XMONITORING 7 ( GROUT SEAL PUMPED: ❑Y. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yw CIN. S APPROX.DEPTH ) D LOCKING CHESTER BOX/STOVE PIPE 5 PROPOSED CONOTRUCTIONMMLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HE9E8Y CERTIFY THAT 1 NAVE PREPARED THIS APPLICATION AND THAT THE WORK 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 WINCH THIS PERMIT is ISSUED,I SHALL NOT EMPLOY PERSONS OMJZCT TO WORKMAN'0 COMPENSATION LAWS OF CALIFORNIA,' CONTRACTOR'S HIRING OR BUD-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS IOBUED.I SHALL EMPLOY PERSONS BU&NCT TO WORT WAN'0 COMPENSATION LAWS OF CALIFORNIA.- T APPUCANT M IT CALL 24 '011�0�IN'JtDVANCE FOR ALL REOIRAED INSP�N©O AT 1200)4OOatit, COMPLETE DRAWING AT LOWER AREA PROVIDED. /`/\,J fi /J dyrF'` Title Date �- qw�dX - �. PLOT PLAN IDr.w to 900161 Sed. '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.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL OYSTEMO. 3. DIMENSIONED OURINF.O AND LOCATION OF ALL EXIOTNO AND PROPOSED __ S, LOCATION OF WELLS WIT/NN RADIVO OF ONE HUNDRED FIFTY FT. ON THE PROPERTY OR ADJotwNG PROPERTY. Post-it°Fax Note 7671 a pa°gesD L 1_( To r � l Co./Dept. Co. ` Phone# Z S# 2 Phone# .....:....... v ;.......:....; .....: . Fax# Fax# V02 ONLY APPBe.11en Ae..Ptttd By 0.1. A—____--_-C Gt I—Pemtett By rouO.t. PumO r»Peetlen Oy D.t. o—w.tlen In.p-0—BY DO.. c �l CommerN.• ACCOUNTING ONLY: AID# FACT A PE COOED FEE INFO AMOUNT REMITTED CHECKS/CASH R OY DATE P13WRITISERVICE REOUEST NU MnER INVOICE P,00i 54 2 Pub Health Serv.-Enviro.173(1/97)