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)"OPLICATION FOR WELL/PUMP PERMIT SAN J 'UIN COUNTY PUBLIC HEALTH SERV .S r-NVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompI9t9 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 WF711 SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. !0 5 #C Cx5 JOB ADDRESSIOR APN#16/Z7 41o(r(/[!Q/f/D Rn CITY C/,y ZOP PARCEL SIZE/APN# OWNER'S NAME Ll/•/�. Sly-/I�C:OT ADDRESS /6 777 H�YvZr1N,D �Y/�. PHONE R 2oy CONTRACTOR T/eew,-lr -C,Pi4 ADDRF.SS2o2 V1jL Ig5Xv/NPj;c✓y uC,r PHONE# I Y7 -6610 SUB CONTRACTOR C6 4RK AlGrZL l/VC . ADDRESS-2a2'V Cc. R7-,-,C w y j, UC#3 7/54 0 PHONE#q4 Z-74 7G TYPE OF WELUPUMP; ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL# PW I Z- ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# 11New C1Repalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O HYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING R ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 1�J (' DIA.OF CONDUCTOR CASINO �^ D ElDOMESTIC/PRIVATE 1:1 GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC //GG/ DIA.OF WELL CASING6.16 ZJ- ^lV1J• D 11PURLIC/MUNICIPAL El DRIVEN DEPTH OF GROUT SEAL 7' Q6oVC 5Ce ee/j SPECIFICATION ZJ&`C G& L/C�71yC�7/ S ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLEDBYCLARK GROUT BRAND NAME /i'CS>z�'N E El MONITORING GROUT SEAL PUMPED:K�g]Yaa [IN. CONCRETE PEDESTAL BY DRILLER:❑Yes [IN. S APPROX,DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIOWDRILUNO ME714OD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE9EBY CER IFV THAT 1 IIAVE PREP THIS IC ATION A AT THE WORK LL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATION OF HE SAN JOAOUIN OU E OWN An LIC NEED AGENT' S GNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT ISS ED,1 SHAIL NOT MPL V ON SU EC TO ORKMAN'9 C M 9ATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE TOLL O: CERTIFY THAT 1 TH PE O ANC OF E O OR NM1TI Hr HIS PERMIT IR ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COM AATIONrWS OF CAUFORNI T US S N A VA OR TO REGU11� INSPECTIONS AT 12091499-3423. COMPLETE DRAWING AT LOWER AREA PROVIDE 71 SIC—d X. C.� 1 • \ ,i Date / PLOT PLAN IDraw to Seale! is 'to 1. NAMES OF STREETS OR ROADS EAR ST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL RTEM OR POSED 2. OUTLINE OF THE PROPERTY,GIVI G MENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTE S. 3. DIMENSIONED OUTLINES AND LOC ON 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. -- G a�/sC .gvE•vv� �� ..... .. . . . .. mPw)2 ...... . :. :.... AfyN _ /9s-!yo 03 . :.. . ... .::. ...... ..... .. . DEPARTMENT USE ONLY Appllcatlen Aeeepted By_ �N�//v"W \ I/I V`�� Dala �L�/ / Ares Orptd Irapeptbn By ttV�i Dste Pimp Inspectlen By Dtle on.rnrtlen I—P—flo By Dete C.--.,t.! ACCOUNTING ONLY: AID# FAC# PE CODES FEE INTO AMOUNT REMITTED CHECK#!CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE zq01 / / 4 Pub.Health Serv.-Enviro.173(1/97)