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APPLICATION FOR w.ELLIPUMP PERM SAN JOAQUIN COUNTY PUBLIC HEALTH SEES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (2091468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1, (Complete in Triplicate) - APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOP�M�jEpENTTT TITLE,,CHAPTER`y8-11115.3/'ANNDD THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC{�HE1AL`TH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR A/PPIN(I,/, ! 1 lrt.' lA 1GY'(IT�,'- 1(k/1 CITY 54wi tin �y►r��y,�PARCEL /�BIZE/APN# OWNER'S NAME )Attco f QC�Ds-'164 � c-A +1 � ADDREBSeO �X}7ID✓I�+yr 530 W3ZSC-(304 RgNEI CONTRACTOR W oI.A.p Y1 o Li ✓/-)I I� 4 ADDRESS �3 90/(3310 'INjjjs6CI v&3 PHONE I ct Z SUB CONTRACTOR ADDRESS LIC/ PHONE I TYPE OF WELUPUMP: P(NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL If ❑ OTHER q I( ♦j ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR VAPOR EXTRACTION WELLI W-IQ Lc Ni�i)J ❑New❑Repelr H.P.__ DEPTH PUMP SET_FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B ❑DESTRUCTION: 6 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS + A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION1.r0 IA {'1( DIA.OF CONDUCTOR CASING "�' D f IQQOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OFCASING/STEEL C V DIA.OF WELL CASING gj/IE'GF, D i {{. ❑ RISLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION �" R & ElIRRIGATION/AG 11 OTHER GROUT SEAL INSTALLED BY r 1 /� GROUT BRAND NAME P�.;f- f ria d £ P ❑ MONITORING .'Y 1- GROUT SEAL PUMPED: ❑Ya [IN. CONCRETE PEDESTAL SY DRILLER:Ely. ❑Ne 5 APPROX.DEPTH L V,. LOCKING CHESTER BOX/STOVE RPE 5 �. PROPOSED CONSTRUCTION/DWLUNO METHOD: MUD ROTARY AIR ROTARY AUGER X-'� CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WALL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-I CERTIFY THAT IN THE PERFORMANCE OF THE WOW 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 WOPR FOR WHICH THIS PERMIT IB ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE APPLICANT MWT/,C/y)ErLL�2/1DHOURS IN ADVANCE FOR ALL REOU RFD INSPECTIONS AT 12MI j4,003423. COMPETE DRAWING AT LOWER AREA PROVIDED. Hlgn X C,L,/lLc � I�.G'Tf4- TIM. 6E/%i&?/:.J Det. PLOT RAN Mrew to Sole)Boole '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. r F I DEPARTMENT USE ONLY Applicetlon Accepted By At. Grout Impecibn By DPte Pam,Impatlon By D.ta Detraction Imo.ctlon By Det. Dpmment.: `f" duJ's !v, /li /z s"» ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE