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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �..� ENVIRONMENTAL HEALTH DIVISION �0 BOX 388,446 N. SAN JOAQUIN ST.,STOCKTON,CA 95201-388 88 (209)468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCTAND 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. JOB ADDRESSOR APNI� J a W C/'Sar}e r (A/ `)� l/ /I FP2d X CITY S 1 0CF�t-G y� PARCEL SIZE/APN/ S/FC,R E S OWNER'S NAME LEb AA)N L 1/A VOLP� /v1 J'-5 I4/y� S r<.-t ADDRESS SF-rckf-o.' CN gj-2073 CONTRACTOR 10-1-4p -AJ /A 2TT /I Jo l W h 4 e TjC<.K 97�-k PHONE I-2!! -86 •Z <� ADDRESS 'Ht <'< 5670 UCI505 9a PHONE I/c+38--3 t ' lye I.0 �� SUBCONTRACTOR (7p ('�V�� / InfL, 1 28LS E', I'N Fn- 11/4 7,SZ-0 S ucI S/2-LG f? PHONE S' -I �pF TYPE OF WELUPUMP ElNEW WELL ❑REPLACEMENT WELL ICI MONITORING WELL;/ 11 INSTALLATION ❑WELL SYSTEM REPAIR ElCROSS-CONNECTREPAIR 13 OTHER ❑N-1111VAPOR EXTRACTION WELL R J RYPE OF PUMP) Repeit H.F. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL s C ❑ SOIL BORING 9 DESTRUCTION: -1A 0 r K ILA V',- INTENDED USE TYPE OF WELL CONbTRUC TION SPECIFlCATION$ ❑INDUSTRIAL ❑OPEN BOTTOMCJ�I A DIA,OF WELL EXCAVATION O DIA.OF CONDUCTOR CASING ❑ IC/PRIVATE ❑GRA /'I C It(' D DOMEST _ VEL PACK/SIZE TYPE OF CASINGI6TEEUPVC PVC_ DIA.OF WELL CASING a" ❑PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL .� S - .S I D ❑IRRIGATION/AG ❑OTHER - SPECIFICATION sC 11 PLftA(e �y'a A GROUT SEAL INSTALLED BY SPEC T P VA -w p• GROUT BRAND NAME NPA f C e.ItQ,a•t l E ❑MONITORING p l5 GROUT SEAL PUMPED:11Ye. [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr ❑N. APPROX.DEPTH O,'•F / LOCKING CHESTER BOX/STOVE RPE S ec I1lf box PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY5 Aiq ROTARY AUGER_CABLE OTHER I HEREBY CERTIFY T14AI 1 HAVE PREPARED THIS APPUCATION 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUB-CONTRACTING 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 CAUF I , HE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION$AT 12091468-3423.COMPLETE DRAWING AT LOWER AREA PROVIDED. SI$ned X Tltle O.t._- PLOT MAN I.'='. D—to S..lel Sul. •to 1. NAMES OF STREETS OR ROADS NEAREST O 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. ... .. i DEPARTMENT USE ONLY Applk.t-Accepted BY -mob7 ( 5 Y DMe�A- G—I-Pectl.n BY O.tePump.".Pooh..BY D.t. D-t,-tion I-p.etlen BY / l�� Common ACCOUNTING ONLY: AID, FAC, _ PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE PERMIT/$91VICE QUEST NUINB@I INVOICE 5 33qq 1. JJ?L 0Xxx