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)PLICATION FOR WELL/PUMP PERM. SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compute in Triplicate) 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 TI-T7LE,CCHAPrER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION./0,S A,-d,(=S JOB ADDRESS/OR APN/ 18 77/ 1I6'12W.//I/U0 RQ CITY Z-V7,/ op PARCEL SIZE/APN#Pi, `NO OWNER'S NAMET� ADDRESS /G 777 �fJLAiv,& RO PHONE R q CONTRACTOR /ZCi7T��C—moi ,7 ADDRESS IO 2 �K4,1 492-1WIV P,!G✓)' uco PHONE/ AY3,-XY& SUB CONTRACTOR �CADDRESS ZD Z Y,6:- `//AiRJ`(7ie W4/ 1 UC I'7/SLy PHONE#v6 L-7(, 76 TYPE OF WELLJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 0 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL� ❑ SOIL BORING R DESTRUCTION: E/IlT i INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ OOMESTICR'RIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Ye• [IN. CONCRETE PEDESTAL BY DRILLER:❑Ye• ❑No S ` APPROX.DEPTH 73 LOCKING CHESTER BOX/STOVE PIPE 5 PROPOSED CONSTRUCTIONtMLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY T14AT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND nFrUt.ATIONS 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,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S IIIRINO OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN TLWI"FOPfAANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN't COMPENSATION LAWS OF CALIFORNIA.' ' A CA MV tllr 2YI al IN jAON7FOR ALL REQUIRED INs//rr ONt AT/Itoal A/e^$�/3�(t/27. COMPLETE DRAWING AT LOWER AREA 771 , a 1 Blgned% Title I,,';l C6 'V I !l- L'l.��l l� D., tj [ PLOT PIAN(Dr to Sole)Scale 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMFNSIONED OUTLINES 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 PROPERTY. . ... i i : . DEPARTMENT USE ONLY Application Aepepletl By - V\� I Wr"l_� DMe I -�1 Are• Grout I—P-11M By Date Pt P Impectlon BY Date De•tnteUon Impectlon BY D•te 1. Commettte: ACCOUNTING ONLY: AID# FACT PE CODES FEE INFO AMOUNT REMITTED CHECKIlCASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUv1BFR INVOICE V Pub.Health Serv.-Enviro.173(1/97)