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APPLICATION FOR WELL/PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION FA 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Camplttt IB TTIpDeatt) APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE W714 SAN JOAQUIN COUNTY DEVELOPMENT TITLE, 1115CHAPTER 1 16.3 ND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESWOR APNI /l�// V = D `�CI4-- PARCEL SIZE/APN# OWNER'S NAME ADDRESS PHONE R CONTRACTOR ADORE 8.9 —� UC o3 f PHONE�� OUR CONTRACTOR UCI PHONE TYPE OF WELUPVMP; ❑ NEW WELL ❑ REPLACEMENT WELL •MONITORING WELL f ❑ OTHER �� ❑ INSTALLATION ❑ WELL SYSTEM REPAIRCRO88-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑New❑Rep•1, H.P. PTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PVMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL J ❑ SOIL BORING R ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMESTIC/F'RIVATE ❑ORAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO O ❑-, PUB /MUNICIPAL ElDRIVEN DEPTH OF GROUT SEAL SPECIFICATION R L5d'IRflIOATK)N/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Y•• [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED tTAUC 170N LUNQ METHOD: D ROTARY R ROTS AUGER CABLE OTHER I HE9EBV dEWIFY THAT 1 HAVE PRE"O THIS APPLICATION AND THAT THE WOR(WILL BDONE IN ACCORDANCE VATH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REOLILATIONS OF THE SAN JOA OUNTY. HOME OWNER OR LICENSED AOENT'S 910NA URE CERTIFIER THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN't COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-CONTRACTINO SIGNATURE CEFMFIES THE FOLLOWING: '1 CERTIFY THA M THE Pf RMANCE OF THE WOW,FOR WHICH THIS 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIONAM'S COMPENSATION LAWS OF CALIFORNIA.' T A CANT MV T CALL 4 URS IN VANCE FOR ALL REQUIRED INS N•ATI I Oaf-2423. COMPLETE DRAWING AT LOWER AREA PROVIDED. 8lpned X Tltl• Det• /�� /'rV� PLOT PLAN fDrto So•1•I 8e•1• 'to 1. NAMES F STREETS OR ROADS NEAREST TO OR BOUNDING THE PRO PITY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,OIVWM DIMENSIONS AND NORTH DIRECT N. EXPANSION OF BEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINF.8 AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WTHIN RADIVB OF ONE HUNDRED FIFTY FT. 8TRUCTVRE8,MfCLUDING COVERED AREAS$MH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING Pno .. ..... .. ..;..... i.... .._........... ? ..... .... .. .._ CE!VFG ......i. ....> ............ :. <.. .... . . : . :. .. . �� . ... O c r2Qoo :.. ....... . . .. ..: ... :......:.. . .,..... SAN JOAQUIN MLIC. . .. LINT .:......: ... .....; TR�IIS�� J. ON MFIVq-q�,HFA oo'j _.... ......... ................................. ................. G' / o ARTMEN I U NLY /J 1 AppSo•Uon Aeeepted BY ` ��-/ O•t• I 0 Ar.. �l O—A I—P-4—BY Oats P—P Inepeellon By DN• On•buetlen Imnertlon BY D•te ACCOUNTING ONLY: AIDS FAC/ PE CODES FEE INFO AMOUNT REMITTED .HEC !CASH REC VEO BY DAT PERMIT/SERVICE REQUEST NUMBER INVOICE 7� l D,-h ti„alth Rani -Fnvirn.173(1/97)