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APPLICATION FOR WELL/PUMP PERMIT SA*'QUIN COUNTY PUBLIC HEALTH SEES Co . ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (2468-3420 ORIGINAL NON-REFUNDABLE PERMITMIT EXPIRES 1 YEAR FROM DIKE ISSUED (Compute In Triplicate) APPLICATION IS HERE BY MADE TO THE BAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDANt INSTALL THE WON(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCEWITH BAN JOAQUIN COUNTY DEVELOPMENT TrNE:CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES.ENVIRONMENTAL HEALTH DMBION. //,,�� �J / o�/ / /•30YkL-O 117;rit tl4f' JOB ADORE59/OR APNI13]f /MAIC O/M11 (IPA)6,.-f r CITU�Jr9CA YDN PARCEL 8IZE/APNI (//I $.JL/C/f 3e�+ D Cie �e ��a v!s CS Rbese /40o Ps well . /2 door OWNER'S NAMEC/0 if I[L 72 tL LrII._) ,L 1 C F .E R fOV ADDRESS m_p�Jr/IQy CFF YYLO�• /SZJ PHONER S�G'�eJ2�Srcl�Q CONTRACTOR ADDRESS UCI-PHONE• OL' d• CUB CONT .Z. S':�u �I.v� ADOn6se�'laf ,C19 YY�63 me �OS6Y07 PHONEsSFQ-3�S-581 TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I ❑New❑Fe .I, H.P. DEPTH PUMP 6ET_FT. FIRST WATER LEVEL 0 (TYPE OF PUMPI ❑ DVT-O F-SERVICE WEII ❑ GEOPHYSICALWELL.e ® 6011 BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS I A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION VIA.OF CONDUCTOR CASINO Al 11-4 0 ❑ MMESTIC"IVATE ❑GRAVEL PACKMIZE TYPE OF CAGINGIGTEEVPVC /U/)q / DIA.OF WELL CASING A/1A /� 0 ❑ MBUCWUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL '}'O7t2Irip fvl SPECIFICATION rH.ewrf' fJ yC R 11IRNGATMNRAO ®OTHER GROUT SEAL INSTALLED BY 061))1 rad- Y'Or GROUT BRAND NAME /yh? E ❑ MONITORING GROUT SEAL PUMPED: 0Y.e [IN. CONCRETE PEDESTAL BYURILLER:❑Yr ❑N. A//JI S APPROX.DEPTH LOCKING CHESTER BOX/STOVERIPE _ r� // g PROPOSED CONSTRUCTION/DRILUNG MUMS: MUD ROTARY AIR ROTARY - AUGEq CABLE OTHERdr i /US/1 1 HMOY CERTIFY THAT I DAVE PREPARED THIS APPLICATION AND TIIAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND MUG AND REGULATIONS OF THE SAN"AMIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WN1CH THIS PERMIT 10 ISSUED,1 BNALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAL FOFWIA.• CONTRACTOR'S HIRING OR SUB-CONTRACTMO SIGNATURE CERTIPES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO WOR10,1AN'S COMPENSATION LAWS OF CAUFOIWIA.• TIIE APPLICANT MUST CALL 3/110MS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 11081/1"-1111. COMPLETE DRAWINO AT LOWER AREA PROVIDED. n 61' K /t-- f-- /` TIP. Silo- 60 r— Dat. 7/2L/9 � PLOT MAN IDI.w 1.%WI 6p.1. 'I. 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. t. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF BEWADE DISPOSAL SYSTEMS. 1. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAEKB. ON THE PROPERTY OR ADJOINING FDOPERTY. o Cce /3 DEPARTMENT USE ONLY 9 O Appllea6en Apeeptdl BY Otl. { �� Nu Orem lropBnllen By One Pump In V.tfen By D.R. be.lnceen In.neollon /�.j�D.la (� ACCOUNTING ONLY: - AID! TACO PE CODES FEE INFO MOUNT REMITTED CHECKIICA811 RECEIVED BY DATE PERMITRIERVICE REQUEST NUMBER INVOICE ?�0 Pub.Heaith SEN.-Enviro.173(1/97)