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APPLICATION FOR WELL/PUMP PERMIT �•.- `�S Z_C, ._ 02— SX LSX IAOUIN COUNTY PUBLIC HEALTH SE VES ENVIRONMENTAL HEALTH DIVISION NOv 200 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 4 68-3420 SAN`10HC)P`jN RH�SSNON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,P,�U14,�,1nn Pd1A�HEAD ICompbl• in Trlplkllu) APPLICATION Ig�l�iglm>BW' ADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE.CHAPTE1R 9-1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTYPPUB,LIICC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR AA5 lam,/ LN Z—"-L-1 I-! /�� CITY (�/`•l'/ �T f�-U/ PARCEL SIZE/APNR ( ��l I 7 OWNF R'S NAME /,PNR L- --1)7(,V L �(,'/ le-' f. /S ADDRESS PHONE R J. / -lt- TiCI l�Ifrr.v:�•r- (`i>Y F F� �j`/ `( �, LON41aCT01� liC I�21 L-:S- Fl zl/tt /( ADDRESS 7�7PHONE R_ 7 SUB CONTRACTOR VZ-r.//\)FTh--J) r.-l' ADDRESS ?6;7,; V I��,`.rz F UCR PHONE.: Z�D '"�j5' TYPE OF OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL R / ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIg/ ❑ VAPOR EXTRACTION WELL R J ❑New 11 Repair H.P. DEPTH PUMP SET FT. I' FIRST WATER LEVEL O HYPE OF PUMPI ❑ OUT.OF-SERVICE WELL ❑ GEOPIIYSICAL WELL R SOIL BORING B ❑DESTRUCTION: INTENDED USIE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C/ A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 61— D 'A DIA.OF CONDUCTOR CASING L^ D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEE V DIA.OF WELL CASING 1a- O ❑ PUBLIC/mu NIC IPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION B ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING I GROUT SEAL PUMPED: ❑Ye. ❑No CONCRETE PEDESTAL BY DRILLER:❑Y« ❑No s —y - APPROX.DEPTH L�� LOCKING CHESTER BOXISTOVE PIPE PROPOSED CONS TRUC TIO NIDRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER I HFAFRY CERTIFY THAT I HAVE 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 FOn WHICH THIS PERMIT IR ISSUED,I SHALL NOT �1 OY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HINNG OR SUP CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: CERTITY T11 �� 1 IE nMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' T P T ALL S IN ADVANCE FOR ALL REQUIRED INSP�EC� 4"-s423. PVI jIONS AT 1200)4M423. COMPLETE DRAWING AT LOWER AREA FROD / `IR //f�/� 1)�0Frx7 L �t 4✓ Dae Il Slpned X Tltle � r'' POT PLAN(0—to So.l.)S-10 'to 1. NAMES OF STnFUTS On nOAD(I NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES 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. J. ip D I. ?ono�✓S DEPARTMENT USE ONLY Appll..lnn A..mtdl flyCM'E"" ^' Da. /Ar.. 0—I In•PMtbn By ' Dae I/ p I—p-11—By D.le 0—t-11—In• .Non ny D.I. ce,,,n,e�,t.: oti— w.// -�� '1 ^11t-t,tiw-� �+71L 41 -04-oz 1zn,� S sR�zva3S oK ACCOUNTING ONLY: AIDR )) TACO PE CODES FEE INFO AMOUNT REMITTED CHECK!1d. RECDVED BY DATE PERMITISEAVICE REQUEST NUMBER IN CE 9 �r << v Pub.Health Serv.-Enviro.173(1/97)