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APPLICATION FOR WELLIPUMP PERMIT <br /> *AN JOAQUIN COUNTY PUBLIC HEALTH SERVO <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 <br /> (209) 488.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is here by made to the San Joaquin County for a permit to construct and/or install the work described. This application is <br /> made in compliance with San Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Public Health <br /> Services, Environmental Health Division. <br /> " ) 1L SC' <br /> (;1 city ' Parcel Size/APN# <br /> Job Address/or APN# 17 <br /> 1(L I I <br /> 1 1 Ci X42 Ll <br /> (( ) � �- n:^ i- ('} Phone # :'_(; <br /> Owner's Namel'�1'n �L Ir)c,rlL P {iC -L( /A¢irLLBSAddress ,;r;r)> >( Jai ��/-,.t�'r 1 ,lcA� t. cl <br /> , h' > <br /> j ( ` Phone <br /> Contractor ressNLic#d <br /> i <br /> j. <br /> I ��l tl> # 1j Il. /. 1': - V 3� <br /> Lic# Phone � <br /> Sub Contractor Ll;h I VG It7t��' �L' Address�•C 17t'< �1� [t VIGZPJ �Ih <br /> TYPE OF WELL/PUMP: �, NEW WELL [] REPLACEMENT WELL A MONITORING WELL # LIQ. I I" G� J(� OTHER <br /> [] DESTRUCTION 11 OUT-OF-SERVICE WELL [7 GEOPHYSICAL WELL # [] SOIL BORING <br /> [] INSTALLATION [] WELL SYSTEM REPAIR [7 CROSS-CONNECT REPAIR [7 VAPOR EXTRACTION WELL # <br /> [] New 0 Repair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL <br /> (TYPE OF PUMP) <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> [] INDUSTRIAL [] OPEN BOTTOM DIA. OF WELL EXCAVATION IP t'U`7� DIA. OF CONDUCTOR CASING 1 , <br /> [] DOMESTIC/PRIVATE 'T GRAVEL PACK/SIZE l� 77 TYPE OF CASING/STEEL/PVC J�ylL• DIA. OF WELL CASING �! "V t <br /> [] PUBLIC/MUNICIPAL [] DRIVEN <br /> DEPTH OF GROUT SEAL 10 ( t tr SPECIFICATION �t-r',�-�'i" /T"' 1 '✓ �r�� <br /> �• <br /> [] IRRIGATION/AG [7 OTHER GROUT SEAL INSTALLED 8Y GROUT BRAND NAME YC'1 i L I\n't ) <br /> F; MONITORING GROUT SEAL PUMPED: [] Yes K No CONCRETE PEDESTAL BY DRILLER: 0 Yes GI-No <br /> APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE <br /> PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_ AIR ROTARY_ AUGER CABLE_ OTHER_ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br /> State Laws, and Rules and Regulations of the San Joaquin County. Home owner or licensed agent's signature certifies the following: "I <br /> work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION <br /> certify that in the performance of the <br /> Laws of California." Contractor's hiring or sub-contracting <br /> rsonsa subject tocertifiessignture WORKMAN'SfCOMPENSATION Laws that <br /> of the work for which this rmit is iss ed, I shall employ pe <br /> MUST CALL 24 HOURS IN ADV bE FOR ALL REGV, ED INSPECTIONS AT(209)488.3423. Complete drawing at lower area provided. <br /> i <br /> ,t L l <br /> r � Title �'1'1.VC�j'R�� )Ili 'zT�LI. 1J, ate_LLL <br /> I t <br /> Signed X <br /> LOT PLAN (Draw to Scale) Scale " to <br /> 4. Location of house sewage disposal system 01 <br /> 1. Names of streets or roads nearest to or bounding the property. ro osed expansion of sewage disposal systems. <br /> 2. Outline of the property, giving dimensions and North direction. 5. Location of wells within radius of 150 ft. on <br /> 3. Dimensioned outlines and location of all existing and proposed the property or adjoining property. <br /> structures, including covered areas such as patios, driveways, p Y <br /> and walks. <br /> •u-1 <br /> SFPP PIPELINE--� <br /> (� <br /> -2— - - - T - - <br /> J - FORMER SFPP PIPELINE J RW-2 <br /> ARCADY OIL CO. <br /> 0 D(M/.IUTION <br /> 0-t• 0 • Shallo+9mund-water monitoring well <br /> 1 /J/ •N-16 <br /> `''.':•' <br /> ••� .. ., ... ♦ Extraction well <br /> X X Soil-,,.,/9,-d u d water--Y locallon <br /> '.''�� •N-e X <br /> �-� AGRICULTURAL FIELD <br /> . _ X Figure 2 <br /> SITE PLAN <br /> o so lea ru, <br /> 5110WiNG SURIVEYG L CAi ONS WATER 'f <br /> DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted By <br /> Date Pump Inspection By Date <br /> Grout Inspection By <br /> Destruction Inspection By <br /> Date Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#'ICASH RECEIVED BY DATE PERMITISERVICE REGUEST NUMBER INVOICE <br /> 14-1`5 Y- <br /> I <br /> 1 i i <br />