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APPLICATION FOR WELL/PUMP PERMIT <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> ENVIRONMENTAL HEALTH 304 EAST WEBER AVENUE, STOCKTON, CA 95202 <br /> EERMIT/SE;"Vic'Es (209) 468-3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Umplttt In TripRcala) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TRLIF�CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN <br /> COUNTY <br /> NTYPUBLISC HEJASLpT'H 0 SERVICES.ENVIRONMENTAL ENVIROvNM� ENTAL HEALTH DIVISION,�SION, <br /> JOB ADORE33/OR APNI C'ry PARCEL SIZElAPN/ <br /> 200-0.. <br /> � <br /> OWNER'S NAMEA'YPHONE 5 <br /> CONTMCTOR_ 1 -PL <br /> ADDRESS <br /> UC, !Z�FI D'} PHONE i v..i <br /> C�^� 4 l--tb t�OrS� E ►.,V lf� ��t "� ADOREBa i?! ��N Q+na 1`� �` U`ec� R10NE I %L`) <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELLJLC MONITORING WELL/ 1 ❑ OTHER <br /> El INSTALLATION ❑ WELL SYSTEM REPAIR /❑ CROSS-CONNECT REPAIR Zp� — ` ❑ VAPOR EXTRACTION WELL I J <br /> (TYPE OF PUMP) <br /> IJN—C1R...1, H.P. DEPTH PUMP SET FT. r""�"J FIRST WATER LEVEL 0 <br /> `` <br /> 11OUT-OF-SERVICE WELL ElGEOPHYSICAL WELL I 0 SOIL BORING 1 � CEL`�R('1�� S <br /> 11 D£STRVCTIO N: .4 x 1„, 1-1 <br /> INTEJIDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> L-L !� <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION I " DIA.OF CONDUCTOR CASING /"'�• A <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEVPVC A/4. DIA.OF WELL CASING /�/� /�-• D <br /> ElPUBUC/MUNICIPAL ElDRIVEN DEPTH OF GROUT SEAL G(-`�l�h/�Q.� �L� SPECIFICATION A14-- D <br /> ❑ IRRIGATION/A0 ❑OTHER GROUT SEAL INSTALLED BY ( L � GROUT BRAND NAME �y�GT�Qd�J� E <br /> ❑ MONITORING ' n, / GROUT SEAL PUMPED: [I Y- ®No CONCRETE PEDESTAL BY DRILLER:Ely- ON. S <br /> APPROX.DEPTH XZE� Yx 7JL LOCKING CHESTER BOX/STOVE RPE N•A, <br /> 5 <br /> PROPOSED CONS TRUC TION/DRLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Io*� <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT-8 SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICII <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PER80NS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORMA.- CONTRACTOR'S HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES <br /> THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN't COMPIENBATION LAWS OF <br /> CALIFORNIA.' THE APP() ANT MUST CALL 24 HOURS IN ADVANCE R ALL REOUIRED INSPFCTIONt AT 12001 4"J423. COMPLETE DRAWINGRE <br /> AT LOWER AA PROVIDED. <br /> nery <br /> SlOd% �� TItI. �C.1 �J /J`C_ , y DO. <br /> PLOT PLAN 1D..w to So.1el 8­1._'to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE FROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,OIVNJG DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED t. LOCATION OF WELLS WMMN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINMG PROPERTY, <br /> �t - - . <br /> ..................... <br /> C,���! V A <br /> AVPIIoDEPMTMENT USE ONLY <br /> NIon eeepled By n <br /> Oae L A,w <br /> Oreut Imveotlon ey <br /> Ove Pump In.veetIe By <br /> O...tn,ctlen Imnectlm By <br /> D.te <br /> V V D.ee <br /> c emmer,t.: <br /> w y � <br /> ACCOUNTING ONLY: AID/ <br /> FAC/ <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED By DATE <br /> OI PTISERVICE REQUEST NLIMSFA <br /> INVOICE <br /> Z - - <br /> 00 S Z 36 <br /> Pub Health Serv.-Enviro. 173(1/97) <br />