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APPLICATION FOR WELLIPUMP PERM[ SAN JOAQUIN COUNTY PUBLIC HEALTH SERviCES ENVIRONMENTAL HEALTH DIVISION P,O. BOX M.304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (2091469-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compbt6 In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/On INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELO'2190 MENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC IIFALT14 SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESSOR A/P�NNO '2jy woQ2 A��`��,L„I D A-`/� CIT-/_M�'AJl 7-6" PARCEL SIZE/APH, f� /Q��r S OWNER'S NAME_//��/��•/,��R(T/�K- / �(C�I S�5 �,♦✓ ,./ ADDRESS pp?? PHONE/ CONTRACTOR L3�'I I5C -�rtv_ ovl/1-u-v�'�AL I'vC_ ADDRESS_ /J_VC41� �)C.�� y;�q p ^L A PHONE# U-�1 5 Oct y L 3 PUB CONTRACTOR III , ADDRESS_�[�,I�1�S��y I��SJJ}. UCfL-+ �' ,CIC� ONE f��CJ,� TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# -�❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL f (TYPE OF PLIMPI 11 Now 11Rooalr H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL O 11OUT-OF-SERVICEWELL 11GEOPHYSICAL WELL# SOIL BORING_-7 X -j 57610ib6 S 11 DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS /� A 11INDUSTRIALINDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 15 N DIA.OF CONDUCTOR CASING 0 ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC N/p DIA.OF WELL CASING QIA 0 ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION ❑ IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY 1 L..LC� GROUT BRAND NAME <' TLPt9 E ❑ MONITORING GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER:❑Yea CIN. 5 APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE 5 PROPOSED CONSTAUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHERGeV-?Rz)13t. I HERFRY 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 AOENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERrOnMANCE OF THE WORK FOR WHICtI THIS PERMIT IB ISSUED,1 SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED I NSP ECTIONS AT 12091460-1423. COMPLETE DRAWING AT LOWER AREA PROVIDED. SIgnod X�1/xy-A`��"�-�`'r 1 Tltle V a��.L kS i r ��1 D�� Date BC�rls�O F YAW dlOTPLAN(D�to Bowel Scale "to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNOINn THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROTOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTUNF8 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. DRAL>,►Pt-� t'. SItoP �r 13o¢rwt�jLoc-hr L7- 1' } .4 WAS + 4j, , S� M A? I Q . . .......:........ - � I 7. / DEPARTMENT USE ONLYwv llcatlon Ameptd B P Y AO e ArwGrout Impeattion By De Pt�P Inapeetlen By Dats Dewrmtlon Impaction BY Data CommerAc ACCOUNTINO ONLY: AID# FACE PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 2S q/z V V 750 Pub.Health Serv.-Enviro.173(3/96)