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APPLICATION FOR WELL/PUMP PERM+'- SA6mA)AQUIN COUNTY PUBLIC HEALTH SE6,fCES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 IION•RfFURDA9LE PEARIII EXPIRES 1 YEAR FROM DATE ISSUED APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCTtIANDfOhipRCINSTALL THE 14 W DESCRIBED.T141S APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAN J'22OAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSmR APNI J �; hh t'19,� OWNEA'S NAME CITY PARCEL SIZFIAPNI i,l��'OZO--/1 ADDRESS �. T7 —`— CONTRACTOR �/ry-� PHONE I ADDRESS. "TVv� S U RUBCONTRACTOq b 1l - PHONE11�__`TCrJ 11---f1 ADDRESS 2 UCI 1D7 9t� I.��'� TYPE OF WELLAPL7MP• LY'NEW WELL ❑ REPLACEMENT WELL 11.0ONIroRING WELL IV ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ OTHER— — ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL ❑New 13n".1, DEPTH PUMP SLIT J RYPE OF PUMPISLITFT. FIRST WATER LEVEL _ a ❑ OUT-OF-BERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING ❑DESTRUCTION: S INTENDED USE TYPE OF WELL CONSTRUCTION Sp ECIFICAi10Ns ❑ IrvbUBTRlAL OPEN BOTTOM VIA.OF WELL EXCAVATION / ` � ❑ WMESTICIPWVATE ❑GRAVELBOOT K781ZE L�,' VIA.OF CONDUCTOR CASINO F�Y't— D TYPE OF CASIN01STEEU{ UJ✓ _ INA.OF WELL CASINO— II Y ❑ PUSUC/MUNICIPAL ❑DRIVEN DEPTH OF OROUT SEALo I.. SpECIFK;ATION ❑ 1RRIGATIONIAG ❑OTHER �, R ,�� GROUT BEAR INSTALLED By GROUT BRAND NAME L!`'MONITORING E GROUT SEAL PUMPED: ❑Yeo []He CONCRETE PEDESTAL BY bRILLER:❑Yr ❑No S APPROX.trE7N� J LOCKING CHESTER BOX/STOVE PIPE PROPOSED CONSTIRICTIONAOISlLINO METHOD. MUD ROTARY AIR ROTARY AUGER— %I-' CABLE OTHER S 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE 1N ACCORDANCE WITH SAN JOAQUIN COUNTY OROINANCEB,STATE LAWS,AND RULES A110 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 FOR 4vHICH THIS PERMIT IS 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 CERTIFY THAT IN THE PERFORMANCE OF THE W01K FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- TH€APPLICANT MUST CALL 24 HOURS IN AbVANCE FOR ALL REQUIRED INSPECTIONS AT 1200 499-S427. COMPLETE DRAWING AT LOWER AREA PROVIDED. TIV �at bele PLOT PLAN 1Drow to Rowel Scale .16 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNnING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR pnopOSED 2. OUTLINE OF THE PROPERTY,GING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 7. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. LOCATION OF WELLS WrTMN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. � Y:MENT MAY 4 '2998 SAN dAO LIO EATH$ E VIR N zW CiUiVTY MENTAL HEAL TH N SIGN _� :...... .... DEPARTMENT USE ONLY 1 r AppAco0en Acoopted BY Dote A," , Cir r Oraut Mapeertan By Oo1e R'Ump Impeottan By Date Deatnmtlen Inspection BY Date Comm"mc ACCOUNTING ONLY: NOR FACT PE COVES E INFO AMOUNT REMITTED CHECK#XASH RECEIVED BY DATE P13WITI80MCE REQUEST NUMBER INVOICE lei 4d2&xj1� ug 514 ,qg - b s YR Pub.Health Serv.-Enviro.173(1197)