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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468=3420 NRH-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUER (Cempl616 In TripRwt6l APPLICATION IS HIM SY MAGE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR( DESCRIBED. THIS APPLICATION 16 MADE IN COMPLIANCE WOH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DMSION. C.Y� CLr r. s ;p.< : gv7J gyF , 1 JOB ADDRESSIOR APNF OFLY� l:yG y'H )1(' YP lI',i;y.-. -� CRY 5ioL)C t& I Cf-i PARCEL SIZEIAMN 07Z ' 4Z0 OWNER'S NAME TOSCc' �11u �na) Cr+.yp :31W' ADDNES87Jt•'VAe' dµ Ey /d T - Rwl: 4 R�Yv. Ile I L, 9566e RHONE It S/Q: ,17(j - ZHIb L,b H.5J I:] o 't- 1. ( / yK11Z B'iKus ILrk Pet: :..-: 1c 4r LHSNrRACTpR 5E(C12 .t L+$rlw „ oetw. . , :I H,: - AODPEeB S:.cmJN�+ir. r.•I J�S4-.'.7 UI i2G Ce t6c PLIGHT 9f TCSCONTRACTOR MN)hYi4.I:YS tri LCL,H ADDRESS %J: uc# 7i6. 7 .t �LL A:1r. C :�Fa C'Y RHONE S �73'T{ • Y,3:k; � 7 `1 . TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL I_y ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CAOSSCONNECT REPAIR ❑ VAPOR EXTMCTION WELL P -/ ❑ Now ❑ Rover H.P. DEPTH PIMP SET FT- FIRST WATER LEVEL p HYPE OF PIMPI ❑ OUT-0OVSERVICE WELL ❑ GEOPHYSICAL WELL / ❑ SOIL BORING B ❑ DESTRUCTION- 5-USE ESTRUCTION:DUSE TYFE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL F❑pmN BOTTOM DIA. OF WELL EXCAVATION ly DIA. OF CONDUCTOR CASINO /1/4 p ❑ DVMESTIOIPRIVATE IYI ORAWI- PACKISIZE OZC TYPE OF CA61NGISTEEUPVC � rI Py Lw DIA. Of WELL CASINO rl ❑ PUBUCMUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL 3 �� SPECIFICATION R r❑- IRRIGATIONIAG ❑ OTHER GROUT SEAL INSTALLED BY / f2,rJ< -%- GROW BRAND NAME E LG MONITORING GROUT SEAL PIMPED: Vs ❑ Ne CONCRETE PEDESTAL BY DRILLER: ❑ Y" ❑ Ne 5 +' AFPOO%. DEPTH yJ CC4 LOCKING CHEOTER BOX/STOVE RPE G=1-��,,. n. �;,t. FL.. C. rL Wh-.�.: t k4t� 5 PROPOSED CONSTRUCTIONANNUUM METHOD: MUD ROTARY AIR ROTARY AUGER I// CABLE OTHER I HERERY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE GONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1914ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORMA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: ' I CERTIFY THAT m TEE PERFORMANCE OF THE WORK FOR W HICH THIS PERMIT IS IBSUED, I SHALL EMPLOY PERSONS SUBJECT TO WOM MAN'S COMPENSATION LAWS OF CAUFORMAn...' THE APPLICANT�MUST CALL 24 HOURS IN ADVANCE FOR ALL REGUIRED INERCTIONS AT [38814883458. COMPLETE DRAWING AT LOWER AREA PROVIDED. SlSned 2W , ! ii' 4/L7j Tlllo i-fl[it2- I�'_:i 4: i J'I�s"J+u 4L: K<� - 1�.t.1- Fc.. la;nz�i:.a{ ` D.~i.7 5/ �/ti PLOT RAN [Drew to Saelel Stab ' to 1 . NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PHDIERrv. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR MOMSM 3. OUTLINE OF THE PIIOPERTY, GIVING DIMENSIONS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6, LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY R. STRUCTUM11c INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALS S. ON THE PROPERTY OR ADJOINING PROPERTY. ,TIMI 1� ,, �P DEPARTMENT USE ONLY /,p ApPlloetlno AeeeptM By I`C'I \""�"� � \ Dote P L/ � Y A `d ;\ Area L ' GraU Impact" By Dete Pumv inopectlen By Dote Omlrmilen ImaooSan By 0e19 Comm> ACCOUNTING ONLY: AID# PACO PE CODES FEE INFO AMOUNT REMITTM CNE XS ASN RECDVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE ZS . CCPJB P Z 56 Z/; 1-/j j, Gl ?' DG � Pub Health SEN. - Enviro. 173 (1/97)