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APPLICATION FOR WELL(PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERA cS ENVIRONMENTAL HEALTH DIVISION �� 3 P.O. BOX 386, 304 EAST WEBER AVENUE, STOCKTON, CA 95201.388 (209( 488.3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompiEts in Tripliwt8l APPIJCATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 19 MADE IN COMPLIANCE WITH SAI JOAQUIN COUNTY DEVELOP/M�ENT TITLE,CHAPTER 9-1115..]3 AND THE STANDARDS OF SANT JOAQUIN CO`UUNNTTY/P'UaUUCJHEA�LTH SERNCEB,ENVIRONMENTAL HEALTH DIVISION..? /��/� / JOB ADDRESSOR APN! A1,jl j' /i/G/'// //7y� �b� �J.Z O—�/ CTry< J/i,G-L T[I�/�-p PARCEL SI2E/APN! IL-3-OZ-11 OWNER'S NAME Lco eG 11' I/O/,D/ ADDRESS �O 9GK J n ZO Y // /��> PHONE0Yl�-6768 CONTRACTOR 7>'P6lfY� — [,G4 L{/_ _ ADDIESS270% C fill/Ae/h U' v?. ?09 LE�OOn `A UCJ PHONE#-/) D SUB CONTRACTOR 1.- 1365 (A„Sc zc /C-£T.PuM �XOLJ,PRT/GN //VL fT ADDRESS UC! Sl?2 PHONE lr S-S'7/2 TYPE OF WELLTPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL /� MONITORING WE ❑ OTHER `T 11 INSTALLATION ❑ WELL SYSTEM REPAIR //❑ CROSSCONNECT MrAIR ❑ VAPOR EXTRACTION WELL f ✓ ❑N.w❑R.p.1r H.P. DEPTH PUMP SET-FT. FIRST WATER LEVEL C RYPE OF MMP) ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL! SOIL BORING L� B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION& A ❑ INDUSTRIAL Cl OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO O ❑ OOMESTIC/PRIVATE ❑GRAVEL PACIUSIZE TYPE OF CASING/STEELPVC DIA.OF WELL CASING A ❑ MOUCMUNICIPAL ❑OMWN DEPTH OF GROUT SEAL 13 71;x- SPECIFICATION p ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY ,TWe Cf/'U/y GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PIMPED: ❑Yr CIN, CONCRETE PEDESTAL SY DRILLER:❑Yr ON. S APPIOX.DEPTH LOCKING CHESTER BOX/STOVE RPE s PIOMBED CONSTRUCTIOWDniWNG METHOD: MUD ROTARY AIR ROTARY AUGER 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 ANI REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEN&ATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIEI 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 OI CALIFORNIA.' CANT MUST CALL MXIN DVANCE FOR ALL REQUIRED INSPECTIONS AT UGHI 440J 23. COMPETE DRAWING AT LOWER AREA PROVIDED. slnn.d X t.-. _ /J TIt1e�/"�/O I/_ C / C-1�C/(fX/1 D.te J OT PAN (D,..v w Sp.l.l 6oN. / •Io -3001 - 6 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROMSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE MSMSAL SYSTEMS. 3. DIMENSIONED OUTITNF.S 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. _.i - f.., i_... i....... ...i II 1111 DEPARTMENT USE ONLY Appllp.tlpn A..pled BY D.te Groin Irwpectlon BY D.te Pump lmp«tlen By. D.E. Cpmmem.: ACCOUNTING ONLY: AID# FAC! PE CODES FEE INFO AMOUNT REMITTED CHECK!/CASH RECEIVEP BY DATE P ITIBFRVICE REQUEST NUMBER INVOICE D /S� z O X35