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APPLICATION FOR WELLIPUMP PERMIT '--ISAN JOAQUIN COUNTY PUBLIC HEALTH SERV:vd ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (2091468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete 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 WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ,1 JOB ADDRESSOR APN# 0 S 0,,U•1-H 8 S T,2 E el- CITY STO L IS 1'O til PARCEL SIZE/APNs q-D AGYe— OWNER'S NAME CA DE,rf OF "rA.usADAT-Alro. : 61STAtcrIOADDRESS p0• flox 2,048 S'fOc >w CQ 9sZ03 PHONE# 209. 949. 4443 c � 3235 SvNR,s� gt_va. Wit. CONTRACTOR 6f0&ou LSV t!r r2.O.,M£�/7AL COIUSV 1--A +rS ADDRESS ka,& I, 4,-n4uO GA LIC# PHONE# 911a•kS2.9/19 -14S 7+A- SUBCONTRACTOR ZSUBCONTRACTOR V'I• I.� �I�f LLi..>•C� ADDRESS 4"k rLK:# +1043-B PHONE#22}•3'#•'4•2 _ TYPE OF WELLJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL 9f MONITORING WELL#A4114 MW 13 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ✓ ❑New❑Repair H.P._C/ A DEPTH PUMP SET FT. FIRST WATER LEVEL — 6-T Fz,-4 0 (TYPE OF PUMP) ❑ OUT-0FSERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING 8 ❑DESTRUCTION: A INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 10 =il1CN DIA.OF CONDUCTOR CASING// �U A D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC 4 rtet-r%1J, PVC DIA.OF WELL CASING -SA J. D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 2 ' •0 ss" SPECIFICATION 5 cj.e dj 1t 4O P II G R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E 0 MONITORING GROUT SEAL PUMPED: 14Y.. ❑Ne CONCRETE PEDESTAL BY DRILLER:MYaa ON. S APPROX.DEPTSO F4AA- LOCKING CHESTER BO)USTOVE PIPE Lj -rAFF,C. COUEQ S PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AI UGER1 X X CABLE OTHER 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 REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING' 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' A7CAIUST ALL 24 IN ADVANCE FOR ALL REQUIRED INS '^TTIION&/ATT 11209)466-3423. COMPLETE DRAWING AT LOWER AREA PROM ED. !/! Tide Date Signed x f r AC-G PLOT PLAN(Draw to Scala)Scala to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR 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 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. ....... ...... ..... ... S cEATTFFcr+c o ..tit p.P_ .. . .......Al+�:. � ... .. . .... ` ...: moo.. OaA t z-i- aa _E?f 11.Wlf4 :.. .. .... .: ....:.. 1 DEPARTMENT USE ONLY /%'/P Application Accepted By Date ' �� i S� Area L . Grout Inspection By Date Pump Inspection BY Date Destruction Inspection By / `1 (�,�e,, 5' /; Date Comments: U I/'I }'N.1 (-044ZLd- M•i-l�. 'a g-D 3 ACCOUNTING ONLY: AAO# FAC# ' PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 3 5i 1 'ni