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APPLICATION FOR WELLIPUMP PERMITwk-� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-388 (209) 468.3420 NON•REFUNOABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR 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 SERVIIC`ES.ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNNf AOy I50U�7�H U S79 EE T CITY r��c-I< T O 1133 PARCEL SIZFIAPNN e�Ln 1p1 OWNER'S NAME CA j'- J T ! K C�c,-+a f 1 ON ADDRESS i GX CL O/� A P.O.E.�- IT a- T6 7-3 /' 1 �.1 ,v a+g l 5 f cit a b /� c-1 CONTRACTOR GacG&-j cn o C r10y,n 4.,fa/ l�rLSur do n f'S ADDRESS_�pry-1-d CAW-CC, -C UCS PHONE s 7/6 SUB CONTRACTOR'JI.S tW. S!'rQ`C� A&AAD PC f/oN 1J Si EJC ADDRESS ?'6 Bow iLW C-6 aAjLd-j.a c,1 f p�Q LICS SS2 l Q HDNE• ri/G-173- /1(? TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ® MONITORING WELLY[Al IJ SI IQ1 -f) ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REP R'"• 1 • ❑ VAPOR EXTRACTION WELLS ❑New❑Row, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELLS ❑ SOIL BORING g ❑DESTRUCTION: /-1 A INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION$ A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION �!D- =K{� DIA.OF CONDUCTOR CASING wff D 1:1 DOMESTIC/PRIVATE 13GRAVEL PACK/SIZE TYPE OF CASING/STEELPVC '4- It, AVC DIA.OF WELL CASING �SAG IS D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL ZI - ss I SPECIFICATION q ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY O EST EX GROUT BRAND NAME E X MONITORING GROUT SEAL PUMPED: ®Yee ❑No CONCRETE PEDESTAL BY DRILLFR:MI Yr [IN. S APPROX.DEPTH -+ LOCKING CHESTER BOX/STOVE PIPE 12" rQ f � Ratia "OUC:/P S PROPOSED CONSTRUCTON/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER j CABLE OTHER I HEREBY CERTIFY THAT I 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 SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$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 IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' APPLICANT M CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209)440-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. SIgr „d—Operation--, Manager oete 3-16-99 PLAT PLAN(Drew to Scale)Seel. '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. Z. 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. ... ... .: .. .. ....... .. __. .. .... ... ...... ....... �cE chhc"fl. ..M'AP. _ ... . ......:.. DEPARTMENT USE ONLY /��J/ AppOcetlon Awepted BY Dere L -5 -LS Arae Grout In pectlon BY Dere_Pump I-Pectlon BY Dere Deetruutlen Impaction BY Date COTmervw ACCOUNTING ONLY: AIDS T FACS PE CODES FEE INFO AMOUNT REMITTED CHECKI/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 350 9,9 0(%040 -3 Z