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,. APPLICATION FOR WELL(PUMP PERMIT ANJOAQUIN COUNTY PUBLIC HEALTH�JSERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388,304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 469.3420 I NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Tripliealol APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/On INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNI_ aac:71f 1�k(j A4 n� L�/hot) { IIJ� n �tf CIT-I f1�.// �q)k./^ 4L F'f�j PARCEL SIZE/APN# G^J�^ r' - OWNER'S NAME, �/•1 S RMC(YA�/[f hr,r i+NCI7 ho J J ADDRESS �LW f^�`V"�,�f� 6A G{ t✓ � �( ^)PHONE I /"" j'f CONTRACTOR �U T'�fVC`.-!Y lnf to `-1'IL tf^.lrO 0l'1 /NC ADDRESS Q2�'��(,,?,,O� M.7�'Rf'� �y� UCN �Vot-L7 PHONE/ )"(.'a2i. t1! 1 J� SUB CONTRACTOR_ _ �A t,t!4 j}!r,7�%. ADDRESS�b( I�Ir{t I�t�!� rt T"' d!1 t LIC=I 9 2 2 PHONE I Jt v� t!t/J YJ TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I f ❑ OTHER f ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR SII ❑ VAPOR EXTRACTION WELL I J \ ❑ RYPE OF PUMP) New 11Repelr H.P. DEPTH PUMP SET FT. Il FIRST WATER LEVEL �II J O ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I SOIL BORING S 'h ❑DESTRUCTION: jI I INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS f A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION { !& ,7 ? DIA.OF CONDUCTOR CASINO r/yN D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEVPVC Al ft II DIA.OF WELL CASING 7y rY"' D ❑ PUBLIC/MUNICIPAL DRIVEN DEPTH OF GROUT SEAL .-I(,( f p`I SPECIFICATION i Y I� p S ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BYGROUT BRAND NAME MONITORING GROUT SEAL PUMPED: ❑Yea VN* I CONCRETE PEDESTAL BY DRILLER: Yee ❑No S APPROX.DEPTH � LOCKING CHESTER BOX/STOVE PIPE N //^^ ^ S PROPOSED CONSTRUCTIONMAILLING METHOD: MUD ROTARY AIR ROTARY AUGER I CABLE OTHER Ct'O AR!_r=• I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE 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 WOW FOR WHICH THIS PERMIT IS ISSUED,1 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 THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS IBSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF I� CALIFORNIA.' THE APPLICANT MUST CALL�24HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120011"400-3.4{2?. COMPLETE DRAWING AT LOWER AREA�P-ROO'VIDED. I Stoned X ,,rL'3C . 1 TltI._P,1 �t'("' i PLOT PLAN(Draw.to Boatel Scale 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. I'4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM On PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED t S. LOCATION OFWELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS,AND WALKS.4 ON THE IPROPERTY OR ADJOINING PROPERTY. ...... .... . .. .. .....:..... .... . ..... I( . .. :. ..:.. ..... ...:..... :.......;......:. ..................:... ..... ... . ...:..... ............... ......... .......:....:. . . .... .........:.. .. .. .. . . :...... ..... .........:. t ..... ... ........:... ... .. .. .. ................:............:.... ... .t....:... ..i....'......i..... ._._$.............i..... .. .. .. ......... .....i:.....i ...i... ....:. ....;.......... ..[.....i.. .. i 'A ......i.....:.....i.....:.......:.. .. ...... .. .. .. .. .... ;_....i.... i..... ....i .. .. .. .. .. .. . ...;......:......:.....:.....;...... . i ...:.....:... p : ... ... .. II :......;......:........................................:.............:. .:...........:... ......:..... .. .. .. .. ... : .....:............:............ ...............................:.. ...........�......�..... . I . I .. .. .. .. ......... .............. 'I . .:_....:.....:......:.............i......;... .. .. .. .. � ..... .... :... ..:. ;....:......:.......... !.l! :4 i ...;.. ..:.....::.. It ...:...... :..:.... - .. .. ... :.. ...1 ...... ......: /^ DEPARTMENT USE ONLY r- Application Accepted By i/',d' / / <�r, •L I�,! J1f t Data ! Area Grout Irnpeetlon BY /!1/\ e-C,_fS^� Date + Pump Inspection By II. bate J i Deatnretlen irnpeetlon By - I Date i{ Cemmente! II ACCOUNTING ONLY: AIDA' FACTI PE CODES FEE INFO AMOUNT REMITTED (C HECASH RECEIVED.BY DATEI PERMIT/BERVICE REQUEST NUMBER INVOICE ZTel li. Pub.Health Serv.-Enviro.173(3/96) I{