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A1PPLICATION FOR WELL/PUMP PER ! _ SAWOAQUIN COUNTY PUBLIC HEALTH SOWCES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABEE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED wompleff n Tripilkwal APPLICATION Ie HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCTIANMS INSTALL THE WOW DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WHIZ SAN JOAQUIN COUNTY DEVELOPMENT THU..CHAPTER 8-111116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICra.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR—ARU— N S I/y CITY p PARCEL SIZE/AMB OWNER'S NAME /900&vwe/l Sf, /;?,/ F/- � a IREeeo. ru 9YCof-/97;l RIONEAS/0- -5'j�U CONTRACTOR / ADDRESS UCB RHONE 8 PUS CONTMCTOP /yvy0 .I �a Y % / ADORER e 9S We /��l UC --cA L, -6Ym MORE E.T/O3I3 .Sd�00 TYPE OF WELL/PUMP: ❑ NEW WELL /❑ REPLACEMENT WELL ❑ MONITORING WELL A ❑ OTHER ❑ INSTALIATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 11 J NmY❑Repelr H.P. DEPTH NMP SET FT. (TYPE OF FIRST WATER LEVEL NMR O IJ WELL 11GEOPHYSICAL WELL A I$ SOIL BORING ❑DESTRUCTION: IHTENOED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSqq 11 INDUSTRIAL ❑OPEN BOTTOM pHA.OF WELL EXCAVATION J (NPhpS DIA.OF CONDUCTOR CASINGN/� O 1:1 IIOMESTICBNUVgTE ❑GRAVEL PACK/SIZE TYPE OF CASINOISTEEIO'VC Al/0. /' pHA.OF WELL CASING N Q ❑ NPUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL �[1 ft/ Y gp7,/T SPECIFICATION�� D ❑ IRRIGATION/AG ❑OTHERA GROIH REAL INSTALLED BY C04�rQ P i OUGHT BRAND NAME N/AL E ❑ MONITORING �J GROUT BEAL PUMPED: Q V. [IN. CONCRETE PEDESTAL BY OFILLER;11 Y. owe S APPROX.DEPTH_ d O TPC. LOCKING CHESTER BOX/BTOVE RPE Ala / 5 PROPOSED CONSTIVCHON/DPoWNG METHOp; MVO IbTAPY AIR ROTARY AUGER CABLE OTHER l(S 1 HE9ESY CERTIFY TIHAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE VAT"BAN JOAQUIN COUNTY ORDINANCES,STATE UW S.AND RULES AND REOULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:1 CERTIFY THAT IN THE PERTORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'@ COMPENSATION"We OF CALIFORNIA.' CONTRACTOR'S RISING OR SUR CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING; .I CERTIFY THAT IN TItE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IP ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN-8 COMPENSAHON"We OF CALIFORNIA.- THE ASPUCANIE MUST CAW2,4 Houses IM ADVANCE FOO ALL REOU111ED INSPECTION{AT 121N14{{41121. COMPLETE DRAWING AT LOWER AREA PROVIDED. elPnea x -+LCL. -A.I.G--� TUIe ��1 P I'I a n Q Y- D.I. /97 PLOT PLAN 1D,.R,Sva.l&.I. to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE P OKRTY. 4. LOCATION OF HOUSE BFWAGE DISPOSAL SYSTEM OR RtorDSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROMSEp S. LOCATION OF WELLS WITHIN RADIUS OF ONE HONORED PIETY FT. BTRVCTVREB,INCLUDING COVERED AREAS SUCH AS PATp0.ODRIVEWAYS.ANO WUKo }y w Y It of UI � f _ U \J L \ ,•. L 1 .... L B 1 _� � � . —5,sT' —I r � •, ,8 a O �E AppDEPARTMENT USE ONLY llcetlen AevepiM Py Y/I^L G^✓--�/l(U 0:..Lnvemlen er 0.1. P—P 1,,.P—Den BY D.1. Owbwllen ImnyKt'len 9Y ^ n•� A' 0 S�7 C-1/'Ct_n- � b�f( Demm.,,t- L �'ntrrv_.syDn��e ACCOUNTING ONLY: AIDS FACE PE CODES FEE INTO AMOUNT REMITTED CHECKEICA8H RECEIVED BY DATE PEWAIT/SERVICE REQUEST NUMBER INVOICE 2 21j 13 44 Pub.Health Sew.-Enviro.173(1/97)