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-'PLICATION FOR WELL/PUMP PERMI- SAN jAQUIN COUNTY PUBLIC HEALTH SEF,. �,ES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In TFlplieit9l APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNI 16 777 CITY `'9Tywop PARCEL SIZE/APNR /'79-/*';>'OS OWNER'S NAME ✓ '�' /r"I/�LDT ADDRESS l6 777 AOWZAry.D /2Q PHONE I CONTRACTOR TAeWr'X'-Ceq AODREE;9202. 414-145ey*y LICA'_ ,1 PHONE I'193'G9/0 SUR CONTRACTOR 6VC11 1/VC ADDRESS,2(-52-7/C. C21,IPPII-2lt W9 ' UCI �77 SGy PHONE IgG2 -7671- TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑N-❑R.P.1r H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p LTYPE OF PUMP) q ` ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING _ B ,ofDESTRUCTION: ! -✓' CIC 'i�iG Sgiyf>/��j�'1�/S/�7 �is�Ol�T T/�E /F INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING p ❑ DOMESTIC/1'RIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGMTEEIJPVC DIA.OF WELL CASING p ❑ PURI C/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING p GROUT SEAL PUMPED:CHESTER❑IY. BSTOVE PIPE CONCRETE PEDESTAL BY DRILLER:[IY- ❑No > S APPROX.DEPTH �U /6O �Z WELLS) L PROPOSED CONS TRUC TIO NRTRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HERESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY OROINANCES,STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH 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 THEORMANCE OFT E WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.', r�� CAr MU7LL 114 6 1 ADVA E FOR ALL REQUIRED IJNS/ ONS AT 1212091460-5423.114 /4�T60-54(233. CO)MPIPE DJR/AWING AT LOWER AREA PAOVIDF Sloped X Tllle_ 1...°`+ C CA J/l/ � ONe_ PLOT PIAN(Draw to S.elel Soele to 1. NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROr'OSED 2. OUTLINE OF THE PROPERTY,GIVINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Vt. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. .......... .i ........ .. .. ( ...: . . . . _....... x . .:... ........ DEPARTMENT USE ONLY Appli-ti..A...pted By_ T�-G1�L.0..Ld �) T-�1^�� OM• ` - 1, / Area Grein heeec+bn BY Det. Pump I-P-0-By Data 0-ft Ptlon Imp.etbn BV Oate C.mmenb: ACCOUNTING ONLY: AIMI FACT PE CODES FEE INFO AMOUNT REMITTED CHECK(/CASH RECEIVED BY DATE PERMITISEMACE REQUEST NUMBER INVOICE Zana Pub.Health Serv.-Enviro.173(1/97)