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APPLICATION FOR WELL/PUMP PER' S, )OAOUIN COUNTY PUBLIC HEALTH S- ,ICES Ut\J )T-IW ENVIRONMENTAL HEALTH DIVISION 2q. 5 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 et3U R I G I N A L RON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICempletu In TrI llcstf) APPLICATION IS HERE BY TY ADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNE LO ENT TRLF,CHAPTER 9-111 5.3 AND THE STANDARDS OF 8 JOAQUIN COUNTY PUBLIC HEALT IT SERVICER,ENVIRONMENTAL HEALTH DI ON. Job ADDRESS/OR API# CITY / C( I PARCEL SiZE,/.AFLYJI 2�/, OWNER'S, NAME _ Yj ADORE88 L�+� li✓ CUy/ J/(��I PHONEf 1 \f1E '}3�c1 CONTRACTO 'OY AAk,' A00nESS I.', %��(G�^1��j� �;�/lC�/v �UCf PHONES 07/,S�,Z-32c, SUB CO RACTOR / G ADDRESS_/ W, /,• V�r ��UC P ,r{ONE71 7j TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL f OTHER�rOc�O�1�C I e/1-6j .—ex b ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL f /�- TN ❑New❑Repair H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL O (TYPE OF PUMP) �,�y1 ❑ OUT-OF.SERVIjjC9E WELL ❑ GEOPHYSICAL WELL f � SOIL BORING `J // �7 g Ix DESTRUCTION! 1k(? dVC �eA-j1(�rt(eW well VC-�^tf�& 1 1 i,14ew , treH'1 , l7 r,)-•/ 1Xp,'A ;4eAe tl—ce m�� INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS) ,q , ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION /• 1' DIA.OF CONDUCTOR CASING D ❑ DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/BTEEL/PVC UC-- OSA.OF WELL CASING j hjr D ❑ PUSLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 0 SPECIFICATION R ❑ IRRIGATK)N/AO OTHER TGi)�QI GROl1T SEAL INSTALLED BY 1�^y 1 GROUT BRAND NAME. J ��i7�f C�JE f MONITORING `` t GROUT ee( T SEAL PUMPED: ❑YN. CONCRETE PEDESTAL BY DRILLER:ElY- w o S 6 APPROX.DEPTH_ 1yy\L/Utx LOCKING CHESTER(BOX/STOVE PIPES PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER GPS 1,L')f 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPIJCATION AND T14AT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY OROIN ANCES,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 WHICH THIS PERMIT IS ISSUED,1 914ALL NOT EMPLOY PER80N8 SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- APPLICANT UST CALL 24 HOUR IN ADVANCE FOR ALL EIEOUIRED INSPECTIOFIS AT 12001468-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. 810—d X Title et Q + j D-te 717/00 PLOT PLAN IO,-w to Se-Ie)Sa-Ie to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISP09AL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OVTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED S. 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. IA!j: ......, V� DEPARTMENT USE ONLY Applle-Ilen AmVted By OVe Grout Impectlon By D-te P—p In-peetlon By /l- ll D.»trwtlen Imnoction ,I / Dete CemmM0.: ACCOUNTING ONLY: AID# FAC# tttt� PE CODES FEE INFO AMOUNT RfMITTED CHECK#/CASH RECEIVED SY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE Pub.Health Serv.-Enviro.173(1/97)