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APPLICATION FOR WELLIPUMP PERMI _ SAN JOAQUIN COUNTY PUBLIC HEALTH SERV'ES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 4683420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (ComPMtB In TFIPIkIltil) APPLICATION IS HENS 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 H-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY �P�UB_LIC,HEALTH SERVICES,ENVIRONMENTAL HEALTH OMSION. JOB ADDRESSIOR APN# 1 A S-7S (nJ L-o �V c1 Lt/a✓J^ 2� CITY�j "40 c-K-( 14 PARCEL SIZE/AMff OBl OWNER'S NAME /'S I,PiV1 E�OI1(1 ( F'DQL U G+SII w ADDRESS 1rh�1•I�O,�( /Jy/ou 3. Co7LL0�EY L/.4 PHONE 0510 j/S bU CONTRACTOR Gv!t G` YV L U LT j i T.e (T f I TMC• ADDRESS ��1/ �yV W 2 IL/^�G�- LIC# Ud f ��j,} PHONE#S1D,J/3-r/OO SUB CONTRACTOR •�( ADDRESS Mar+Iz.z3 1 l A . LIC# PHONE 0- TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL fLY MONITORING WELL♦ 3 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ❑New❑Repair H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL O !TYPE OF PUMPS ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ 601E BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL �❑.�IAI OPEN BOTTOM ,,/1I/ II DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O ❑ DOMESTIC/RUVATE 10 GRAVEL PACKISIZE TYPE Of CASING/STEEUPVV� �gI/ DIA.OF WELL CASING 1f D ❑ PUBLICIMUNICIPAL ❑DRIVEN w DEPTH ttt OF GROUT SEAL I Q 1,0V G r�144PECTICATION �Y2�1 C-Ia W 0�/� Rl ❑ IRRIGATION/AG ❑OTHER -9-4.1,2 t GROUT SEAL INSTALLED BY Cf L GROUT BRAND NAME IlV? ]5nd- N.Qq,� LG�tLE✓1 I'm MONITORING �J CI GROUT SEAL PUMPED' ❑V. CONCRETE PEDESTAL SY DRILLER:❑Yr []No 5 APPROX.DEPTH <� �{Qj� LOCKING CHESTER BOX/87OVE PPE S PROPOSED CONSTRUCTIONIORIMING METWD: 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 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: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTMCTOR'S HIRING OR SUB{ONTRACTING 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.�E�A)PPLICANT MUBT CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12"1 4"4Pk22. COMPLETE DEWING AT LOWER AREA PROVRDED.y�// Slgr X �//(/V Title Z41e-/ V W/�q�J Date / W • �/ PLOT PUN (DI.to Soalel Sul. V 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR P POSED 2, OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OITMINFS AND LOCATION OF ALL EXISTING AND PROPOSED 6. 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. 5p-,e a,6 of Gke-d Y r I LA Ire Z Ll SL�� +�� 7v�c1 ProPoS'ZG� �O�MJL+ovlx� l,Uf� L,oca�floM1 �� DEPARTMENT USE ONLY Appllpetlen Accepted BY Date_ �� At. - r 0'.0 Imp«Ileo BY Dae flimp Imp«rico 8Y Dae De.umtlon Imp«rico BY D.te cemmenH Ril/�,51 WOtr Y-,- Kw ACCOUNTING ONLY: AID/ FAC# PE CODES FEEINFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PEAMM3ERVICE REQUEST NUMBER INVOICE 350 u112+0