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pPLICATION FOR WELLIPUMP PER AM COUNTY PUBLIC HEALTH S�CES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 • (209) 468-3420 RON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {C9mplet9 In TtipReatol APPLICATION 08 HERE BY MADE TO THE SAN JOAOUI14 COUNTY FOR A P*fWIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOO�pMEHT^�TITM CHAPTER 9-11115 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION JOB ADORESS/OR APNF- rte{ A-L;r- " P,<,, " (4 / RIC-fl, 'F 14' CITY S �C K-It^ PARCEL SIZVAPNO OWNERS NAME C.1 r� - C ' SIGC �; 1 I ADDRESS PHONED E--Cir3 Y y CONTRACTOR 1 Ary - LL 1)�/f G / rj �` -I ?n, ;ucs v ' PNOHE:7�T i I/ ]I ADDRESS_ �} 14 _ G r' 2 fG< f L�j' < Sr - J.. RUB CONTRACTOR ADDRESS Lich PHONE a TYPIE OF LUTUMPt ❑ NEW WELL ❑ REPLACEMENT WELL �M NrTOInNO WELL f ❑ OTHER ❑ INSTALLATION ❑ WELL BYOTEM REPAIR Cl CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL 9 J ❑Naw 011apa4 H P DEPTH PUMP SET TT FIRST WATER LEVEL- � � O (TYPE OF PUMP1 ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL 0 ❑ BOIL BORING B ❑OEBTRUCTION I INTENDED USE TYPE OF WELL CONSTRUCTION GFECIFICATION ,l, A ❑ INDUSTRIAL -e❑�OPEN BOTTOM C�� VIA OF WELL EXCAVATION P -;•IC/'� r A p1A p¢CONOMtOR CABIHG ❑ DOMESTICIPRIVATE —GRAVEL PACKMZE4— .if A, TYPE OF CASYNOMTEEUPVC_ P�r _. _ DIA OF WELL CASINO Z- d- [a ❑ PUSLICIMUNICIPAL (❑DRIVEN DEPTH OF GROUT BEAL 1 F,,:.i 4� nF i SPECIFICATION f l��_ .YV/� R }❑ IMOATIONIA43 ❑OTHER OROUT SEAL INSTALLED BY T,'�i�.II}c A r!?�- GROUT BRAND NAME._e*d EL.I Al MONITORINGr, GROUT SEAL PUMPED r ❑No L-Cr CONCRETE PEDESTAL SY DRILLER^Yw ❑Ne S AM"OX DEPTH__ (Z_/ LoCXING CTgvtvR BOX19TOVE PIPE `LCL L hr?c S PROP09EO CONATRUCTIONIVR1L!1114143 METHOD MUD ROTARY At"ROTARY AUGER-,2f—CABLE OTHER I RMBY CERTIFY THAT 1 HAVE PREPARED T1418 APPLICATION ANG THAT THE WORK WILL,BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES STATE LAWS AND RULES AND REOULATIONS OF THE SAN JOAOUIN COUNTY HOME OWNER OR LICENSED AGENT S SUONATURE CERTIFIES THE FOLLOWING T CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TWO PERMIT IS ISSUED I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN 9 COMPENSATION LAWS OF CALIFORNIA CONTRACTOR 9 HIRING OR SUB{ONTRACTIHG SIGNATURE CERTIFIES .THE FOLLOWING I CERTIFY THAT IN TItE PERFORMANCE OF THE WOW FOR WHICH TWO PERMIT TO ISSUED I SHALL EMPLOY PERSONS BUINIECT TO WORXM^WS COMPFTNSATION LAWS OF CALIFORNIA' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUMIM INSP9CTGON9 AT 12091400-2-112S COMPLETE DRAWING AT LOWER AREA rrISIP"OV`KKD SN".w X , L'V Y I G !�.. TF.-N ST F-F Cid c /("515 I Dates Vr C l ^ C! PLOT PLAN Mrow is%WW Beale 'to 1 HAMER OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY 4 LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2 OUTLINE OF THE PROPERTY OWING DIMENSIONS AND NORTH DIRECTION EXPANSION OF SEWAGE DISPOSAL SYSTEMG y DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED S LOCATION OF WELLe IIIITIKN RADlU8 OF ONE HUNDRED FIFTY FT STRUCTURES INCLUDING COVERED AREAE SUCH AS PATIOS DRIVEWAYS AND WALKS ON THE PROPERTY OR ADJOINING PROPERTY EE!O*v USE ONLY 1 %ov4aetlan Aowmted BY I �r' '/rte Dn• / ~� M� �� Oroul ImPeetlen By One F Inepaelen By Dh• De.tnrellen t. oeellen Hr Data Cammenla � ACCOUNTING ONLY AID/ FACIT PE CODES FEE TNFO AMOUNT RIMG/T�T7E(D CHECKPICAS" RECHvED BY DATE POMTISUMCE REOUEYT NUMB91 INVOICE 3,67 7 Pub Health Sefv Envlro 173 (1/97) -- t r