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APPLICATION FOR WELL/PUMP PEP' _',T k.,�V JOAOUIN COUNTY PUBLIC HEALTH 4w6VICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (O mpk(e in Triprkals) APPLICATION IB IIERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDlOR INSTALL THE WOW DESCRIBED.T4118 APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER$-1116.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC NEALTII SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOS ADDRESSlOR APN! pV41-1) I`f7— y� ��•+ CITY PARCEL SIZFJAPNf beL�gOWNER'S NAME iG l(.G— ADORES .0 Ems_ PHONE f CONTRACTO � ADDRE88 -.n�,Q�L[:� '; LIC! PHONE R RUB CONTRACTOR 6C �36��6lcJ �� LIC! ADDRESS �C.{:TLV�� PHONE!7�G f TYPE OF WELLlPUMPI ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL a ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL! ❑New❑Repan H.A. DEPTH PUMP SET. FT. FIRST WATER LEVEL O (TYPE OF PUMPI ❑ OUT-OF-SERVICE WELL ❑ OEOMIYSICAL WELL! lwSOIL BORING �`S% - a Zi-Tdo,a INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS// r A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION �l VIA.OF CONOUCTOR CASINO D ❑ DOMESTICMFSVATE ❑GRAVEL PACKIBIZE TYPE OF CASINOISTEEtJPVC ..--.� DIA.OF WELL CASING Q ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL �e -- SPECIFICATION q ❑ IRRIGATKIN/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MOMTOMNO / GROUT SEAL PUMPED: ❑Yee ❑No CONCRETE PEDESTAL BY DRILLER:❑Yee ❑Ne 5 APPROX.DEPTH �� LOCKING CHESTER BOXJSTOVE PIPE S PROPOSED CONSTRUCTIONIDMLUNO METHOD: MUD ROTARYAIR ROTARY AUGER A CABLE OTHER I HEREBY CERTIFY THAT I IIAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCEB,STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWINO:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,i SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAItFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIONATURE CERTIFIES THE FOLLOWING: 'T CERTIFY THAT IN TILE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WOR"AAN'S COMPENSATION LAWS OF � CALIFORNIA.' T PPLICANT MU ALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION*AT tt"Ill"48 *4.22. COMPLETE DRAWING AT LOWER AREA PROVIDED. /p Slpned% Tltle �X J� � C- t�(.iC �]1.�!'$' �- Dete. / /Z& PLOT 7— PLOT PLAN IOtew to Boelel 8ada�'te•�� 1. HAME8 OF STREETS OR ROAOS NEAREST TO OR BOUNDING THE PROPERTY, 4• LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE WIOPERTY,GIVING DIMENSIONS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 7. OtWNSIONtO Ol1TLINFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDWO FIFTY FT. { STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY, i ly ..........:.. .i.....E.....> .... .. .. -- ... - I .... ....... .. I . .. .,..-. .. -...-. E... ' .. .. .. .. - .. .. .. - .. _ _...: .. ... .. ... .. .. .. - 4. .. .E.. ..'`'. -..... r .. .. ..:, ;, ......-. ............... --- - .. ... .. DEPARTMENT USE ONLY �t O p APpBaetlon AeaWled BY r Date /V-��y -y0 _/Pee d7� G�eut.1-p erlen SY�- —�-�` �f _ _-lac^.- to _ _ �AenP InMactton 9y' N (�1;1 �Y Vowmn don rnrpeetlon SY WLL'L'e'"�' Date^ ra—moe: ACCOUNTING ONLY: NO# FAC# PE CODES FEE INFO AMOUNT REMITTED HEC !GASH RECEIVED BY DATE PWMITlSERVICE REQUEST NUMBER INVOICE Pub.Health Serv.-Enviro.173(1/97) y - z