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APPLICATION FOR WELLIPUMP PERMI SAN JOAQUIN COUNTY PUBLIC HEALTH SEES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED n Triplicate) APPLICATION IS HERE By MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCTIAND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SA JOAQUIN COUNTY DEVELOPMENT TALE,CHAPTER 9.1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNF _ �� / l^�If-ff-, CITY �/ �� jp�J /(y�.,2 3Y- 77X( " (i'j7 PARCEL SIZE/AMI C OWNER'S NAME-II O / /, 4 ADOREse I-111St (7 (, `,[ ',!{{' IS jtfCel4 PHONE 14/ 1 Z .Z'�L CONTRACTOR /L4ilti�>/.V�t 1Y)YYYI YnI'r� //3's�':I'�✓-%�O,r 6-5 / ADDRESS QO+y<I,V -p >�r r lQuc UCI 2 L�F= PHONE t 6.53• IQ 'y SVS CONTRACTOR _ "^7 ADDRESS -� i.�- UClPHONE• TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHEfl ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROS"ONNECT REPAIR ❑ VAPOR EXTRACTION WELLf J RVPE OF PUMPER 13 N.w❑R.P.Ir H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL C❑DESTRUCTION: PH �/t( ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL A yeBOR 1 ,7 BORING Lo Z / S INTENDED USE TYPE OF WELL CON8TR11CTION tPECIFHCATIONt ❑y INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO NO Pl0 A LEI DOMESTIC/PSVATE ❑GRAVEL PACK/SIZE TYPE OF DIA. "p /y O DIA.OF WELL CASING /(c w' D ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL Seti' I�I SPECIFICATION 4✓14 ❑ IRRIGATION/AG MOTHER GROUT SEAL INSTALLED BY �LNI I'LTTt bc' GROUT BRAND NAME ,.'0�pr R ❑ MONITORING GROUT SEAL PUMPED: aY. ❑No CONCRETE PEDESTAL BV DRILLER:❑Y. ❑N. S APPROX.DEPTH 2-5— LOCKING CHESTER BOX/STOVE PPE 5 PROPOSED CONBTRIOTON/OPoLLING METHOD: MVD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPAPED THIS APPLICATION AND THAT THE WOR(WILL 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 WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN't COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' T 1 AP ANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED/I1NSMIRONtAA )12001480 23. COMPLETE DRAWING AT LOWER AREA PROVIDED.slams x TIB. C Gd�SC//17?<9//— D..i z,/96 1. NAMEPLOT PLAN(D,.t.8.N.1 S.I. 'to 1. NAMES F BEETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 2. OUTLINE OF THE P oREM,GIVING DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF HOUSE SEWAGE OISPOSAL SYSTEM OR PROPOSED 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PHOPOSEO EXPANSION OF SEWAGE DISOBAL SYSTEMS. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT, ON THE PROPERTY OR ADJOINING PROPERTY, t mq DEPARTMENT USE ONLY APPIi..tl.n Ac."tW BY `tet ° Vb D.t. 11 ( Y/ A,. Grout ImP.otl.n By PumP In.P.tlon By D.t. Dw,.tlon In.P.11.By �[ Do. ACCOUNTING ONLY; RID/ FACT PE CODE) FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE PERMIT/tERVICE REQUEST NUMB9L INVOICE 1�