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?PLICATION FOR WEL'L/PUMP PER. SA, ..JAQUIN COUNTY PUBLIC HEALTH SEtivICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OFPN JOA COUNTY PUBLIC!{EALT!{SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# T'L[.,e `-S//rT /LL i-� � Q.. : b �(��V �Z'`LPARCEL SIZE/APNM�(��'� C,� OWNER'S NAME �—In L` �K O. ADDRESS � C „�I / F41ONE• CONTRACTOR (�1 L"��l''K�'�tL-�� ADDRESS?"JZ'� . (]/YI y94:-TL�- IJC+I J PHONE R ✓ SUB CONTRACTOR ADDRESS UC# PHONE# TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL Jr {ER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR VAPOR EXTRACTION WELL# J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PVMPI 'pry`❑ / ^,,OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# pr SOIL BORING AkLJ� A- -169 La B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ,A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION ,OF CONDUCTOR CASING p 11DOMESTIC/PRIVATE EI GRAVEL PACK/SIZE TYPE OF CASING/STEEtJPVC DIA.OF p ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E 14 MONITORING I GROUT SEAL PUMPED: ❑Yee [IN. CONCRETE PEDESTAL BY DRILLER:❑Yee ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPPPIIIPE RIS PROPOSED CONSTRUCTIONIDLLINQ METHOD: MUD ROTARY AIR ROTARY AUGER CABLE. OTHER I HEREBY CERTIFY THAT 1 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 LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH 1I119 PERMIT 15 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I THAT IN THE PERFOR C OF THE WOW(FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.' TH PP ANT MV A 24 FIO •IN DVANCE FOR ALL REQUIRED 1 NS ATI2/0/0 /tJ-34,21. CC PETE DRAWING AT LOWER AREA PRO/VIDED Slpned X rC e'i Tltie rr ✓ e � Date C D 31 PLOT PLAN 0ew to goals)Sade 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE D19POSAL SYSTEM OR 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. DEPARTMENT USE ONLY ADPllcetlan Aeoepted By DM• Arae 4" —Tier Grout I-p-don By Date P 1 p Inepeatlon By Date 13"t—tion IrnPa flon ffiy Date Comments: � ACCOUNTINO ONLY: AID# FAC/ PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATV PERMIT/SIE(VICE REQUEST NUMBER INVOICE ILZ'0 Pub.Health Serv.-Enviro.173(1/97)