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\PPLICATION FOR WELL/PUMP PERMI— SAN .OAQUIN COUNTY PUBLIC HEALTH SE►. ICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE,STOCKTON,CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In TTlpllcltel APPLICATION IS//ERE BY MADE TO THE CAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER `9/19115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMSION. JOB ADDRESS/ORA�APNF^ TCI/SOv3LA t{I-G WYLiJ(J CRY TU �O✓L PARCEL SIZE/APN[ [�/ [� .WNER'SNAMAAEMlI' (�ACjj/ L 6[1� .� /1MKFIY{ �Y4 YLSFtN I.t> ADDRE86Z �St A+, 1 ►t �"1 PFIONE CZ�I� 7YL��I7© CONTRACTOI�L[rCL'yLC{'�,t"C�R..F--1'IV II nt7.�4yI t,�H�Ii'LC ADORES 1 f- (f , SUBCONTRACTOR CLL✓IYL'D,+6bZ ��?.-,5 E,M11Wi�i1ASlA�C� G7� pp (, (Ly> 1 ADDRE68 UC/ � ZZ�PHONEtL�G ytc—�/y3� 4 11�' `t-- TYPE OF WELUPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL/ y11L OTNER 6QDo t"�r aGOi'% ff. 11INSTALLATION 11WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR 13VAPOR EXEX R TION WELLS ./ (TYPE OF PUMP) ❑N—LIRep.1, H.P. DEPTH PUMP SET Fr. FIRST WATER LEVEL O ❑ORT-OF-SERVICE WELL ❑GEOPHYSICAL WELL$ ❑ SOIL BORING 9 ❑DESTRUCTION: INTENDED U61 TYPE OF WELL CONSTRUCTION SPECIFICATION{ A ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O ❑DOMESTICIP NATE ❑GRAVEL PACK/BRE TYPE OF CASING/GTEEL/PVC OVA.OF WELL CASING O ❑PUSUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑MONITORING GROUT SEAL PUMPED:❑Yr ❑No CONCRETE PEDESTAL BY DRILLER:❑Y.. ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONSTRLUCTION/DRSLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 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 BAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR MUCH THIS PERMIT IB 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 CERT( r IN HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA,n. THE APPUC iT M ST LL 21 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT f28S)4411-3/22.COMPLETE DRAWING AT LOWER AREA/TOVIDEd. . slPa X -� Till. Y`> .IP� l•*r t� D.e.7 PLOT PLAN IOIY.v to Sod.l Sed. •to 1.NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL 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 EXIBTINO 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. I DEPARTMENT USE ONLY G{ App6anon Acc.Pt.d BY q (, D— • A— Orovt Imp«nen Br �,[� !✓\ D.t. l 2L '4 PmP In.P«tton Br ort. D.wvnction Imp«tlon BY D.l. 17 C.mm ACCOUNTINQ ONLY: ALO/ FAC! PE CODES FEE INFO AMOUNT REMITTED CHECK/MASH RECEIVED RY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 350 4`l�op 113y0 Qii y 0 t Pub.Health Serv.-Enviro.173(1/97)