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4PPLICATION FOR WELL/PUMP PERF SAP-cOAQU1N COUNTY PUBLIC HEALTH SEWViCES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE BAN J04OUIN COUNTY VOR A PERMIT TO CONSTRUCT ANDIOn INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER B-111$.3 AND TIE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH DIVISION. JOB AODRER8.11 APJI jg-Vj_ W r-W T40 A4-r01V R Q AO CITY `Q DI /�I� PARCEL SIZ APNI 1 OWNER'8 NAMEn ^�T/ �araK�cl.; ADDRESS 1 Q, n�[ I11 qJ,10 �bNE q�3�9 CONTRACTORAa%knCPO Gen CP1VIlon meedol q IGC. ADDRESS 19 OS W . M4110 `tlA uce 22� T'LIOPIE• 45b-DY SUBCONTRACTOR ADDRESS UCS PHONE# TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CR089 CONNECT REPAIR ❑ VAPOR EETMCTION WELL• J R VFf OF PUMP) 11N—ElFbpelr H.P. DEPTH PUMP SET FT. �yFIIR"WATER LEVEL (' / O 11OUROP.SERVICE WELL ❑ GEOPHYSICAL WELL I qL BOIL BORING PP M /F.J B ❑DESTRUCTION' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS tt A ❑ INDURTRAL El OPEN BOTTOM DIA.OF WELL EXCAVATION 01 IIIc^ DIA.OF CONDUCTOR CASING N D ❑ DOMFAFM WVATE ❑GRAVEL PACKRUZE TYRE OF CABINOISTITL V-C� 1- IVIA/��H L DIA,OF WELL CASING ,v D IJPUBLICRAUNICIML 11DRIVEN DEPTH OF GROUT SEAL r[ITU 1 LKSr�,\ SPECIFICATION WA p R ElIRRIGATIONIAG 11 OTHER GROUT SEAL INSTALLED BY TRCm)C PI�2. GROUT BRAND NAME rpr4krND 7'ym 'F E )RIO NI OMN rrC GROUT SEALOCKINGPUMMOCH❑EBTER B�/BTOVE PPE Aj CONC RETE PEDESTAL BY DRILLER:,4Ys ❑Np S PROPOSED CONBPRL)CTIONIDRLIING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER V P O A.06& .06& I HERESY CERTIFY THAT 1 HAVE PHFPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE BAN JOAOUN COUNTY. HOME OWNEn OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH TIIIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION tAW8 OF CAtIFORNIA.• CONTRACTOR'S HIRING OR OUR CONTRACTING SIGNATURE CERTIFIER T$IE FOLLOWING: •1 CERTIFY THAT IN PIIS PERFORMANCE OF THE WOR(FOn WHICH THIS PERMIT iS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MUST CALL 24 W LA S IN ADVANCE FOR ALL REGURED INNlPECTIONN88(A^ M T Ia148aJ 28. COMPLETE DRAWING AT LOWER AREA PfK)VIDE'DD.. . y e1. I X I M A („� T1R._ Ta7'r Gpnl qi1 OH. /'� PLOT PLAN IVB Ip Bewel 8e.le Ie 1, NAMES OF STREETS OR ROA B NEAREST TO OR BOUNDING THE PWPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2, OUFUNE OF THE PgPERTY,01VIN0 DIMENSIONS AND NORTN DIRECTION. EXPANSION OF*MADE DISPOSAL SYRTEMB. J. DIMENSIONED OITUNFS AND LOCATION OF ALL EXISTING 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 PIbPERTY. DEPARTMENT USE ONLY APWIoBen AeeepleA By- - .�f Del. � Aree�L Oro.Impmlbn By DO. Inn ImpmBun By OHe Dwblcllen Irwnslbn BY D.L. C.—SS. '406( ACCOUNTING ONLY: AID# FACT PE CODES FEE INTO AMOMT REMITTED CHECKIICASH RECOVE SY DATE P9NOTUERVICE REQUEST NUMBER INVOICE o - / 013 711 Pub.Health Serv.-Enviro.173(1/97)