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APPLICATION FOR WELLIPUMP PERMIT ad SAN JOAQUIN COUNTY PUBLIC HEALTH SEh, tS ENVIRONMENTAL HEALTH DIVISION BOX 368, 304 EAST WEBER AVENUE, STOCKTON, CA 9SMI-388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete iR Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE CHAPTER 11_�9-1-�11 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNX729 LOYY/ n1 — L I �/ M CITY s�_�� CA PARCEL SIZE/APN# OWNER'S NAM f uA�DDRESS�2/J�p C ensu t �c�'/' r 9USA PHONE#_2Q7-255-903/ A r-�-�ZE3L��rd ADDRESS Z10�_�/Jh�[� LICA' aalCONTRACTOR M,f�I�L,O/YIL�A3LY1�__ 1/�o 'j2'3� �1� �J PHONE*510-013- p4�0 p ADDRESS±2��a LICA /246 7 PHONE AQ/6 QC7 / TYPE DF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL A 2,_ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# 13 J New 1:1 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL (TYPE OF PUMP) O DESTRUCTION: 1-1OUT-OF-SERVICE WELL 11RI GEOPHYSICAL WELL# ❑ SOIL BONG B INTENDED libih TYPE OF WELL CONSTRUCTION SPECIFICATIONS INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION R !n[�S DIA.OF CONDUCTOR CASING )VIA A 13 ❑ DOMESTIC/PRIVATE 14 GRAVEL PACK/SIZEA&I 3 Ma ' TYPE OF CASING/STEEL z M -diaA� DIA.OF WELL CASING_Z-/rJ—G�/q'h,, D ❑ PUBLIC/MUNICIPAL ❑DRIVEN tr equiV, DEPTH OF GROUT SEAL Z�t1-�� -fp SY 0 (APPX)SPECIFICATION 11 IRRIGATION/AG 11 OTHER 1, GROUT SEAL INSTALLED BY7TQ/7I/C GROUT BRAND NAME At t'F LIYI f �Pdy'f�(�� E �( J MONITORING `/�y ('� L- GROUT SEAL PUMPED: LTJ Yea []No Ne CONCRETE PEDESTAL BY DRILLER:❑Yr ®No S APPROX.DEPTH T6 ?"f pQ E LOCKING CHESTER BOX/STOVE PIPE 7 G—YcrrtCA WdJ IOpK S PROPOSED CONSTRUCTIOWDRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER__CABLE OTHER I HE9ESY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK 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 WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN%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,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS /pA�T(2091469.-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slpned X Title J(J�l ivy l7 (S' � Data 3/5ll&t PLOT PLAN(Draw to Scale)Sole '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 OUTUNE.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. . ... .. ......... .. ...... .. srrf., ALAN . .....:.:... ....::.: .::.:.::.. :: :::::..':::.: ::.:..�:� �.:�.::.: ::.: �.....: .... .. .< .. .:.. ............ FpR . 0CATtoNS_ _O F .1Vti11- aKd. M W ,3 <._......................................... SCALE. A.p�l�olc...... : Zo DEPARTMENT USE ONLY Application Accepted By Date 1 X! Arm L �� Grout Inspection By Date Pump Inspection By Date Destruction Inspection By 0 Data Comments: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE