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APPLICATION FOR WELLIPUMP PERMIw SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IC6mpIBtB in TriplimtE) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER B-11,161.3 AND THE STANDARDS OF BAN JOAQUIN CODU`NTT-YY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIMSIOJN. JOB AODRESSXIR A/P'NO /}a54 y_I^'Pc�;.V.A/l OL/d tY/1SNA CITY JIVL� —t-w PARCEL 812E/APNO 1o(j -Q�LQ-lS OWNER'S NAME._J/T L'1G.V'WA.IAXTT.-I ILS �N fAV IN 1 ADDRESS SR n��.'1 ['p^ PHONE I CONTRACTOR �VI A/ItYbS _ ,LYS�-- ADDRESS P,,00,8px 025 LICE Q ` PHONEIIO71,51 _7 BUB CONTRACTOR _ • - ri lli SIA ADDRESS / V Mo Lye. RdLICI /ly X65 PHONE 0510-313igOD TYPE OF WELLBRIMP: 101 NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I JWW-6 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r ✓ ❑NRY❑Revalr H.P. DEPTH RUMP SET—FT. FIRST WATER LEVEL 0 (TYPE OF RUMP) ❑ OUT-OF SERVICE WELL ❑ GEOPHYSICAL WELL r ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION{p A ❑ INDUSTRIAL ❑OPEN BOTTOM f� /'.•Z%- C DIA.OF WELL EXCAVATION /Jn DIA.OF CONDUCTOR CASING y N �( D ❑ DOMESTIC/PRIVATE JAI GRAVEL PACK/812E1 3 t 5bqr TYPE OF CASINGMTEELIF -J Y U DIA.OF WELL CASING t✓L I/ 0 ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL `' SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT REAL INSTALLED BY Dr i)LU/ GRIM BRAND NAME E 0 MONITORING GROUT SEAL PUMPED: ❑Yr 10NoCONCRETE PEDESTAL BY DRILLER ®Ye. [IN. S APPROX.DEPTH OLV LOCKING CHESTER BOX/SFOVE RPE JaNIt SOX 5 PROPOSED CONSTRIICTION/DRIWNG METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'H CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH 6 THIS PERMIT IB ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBLONTRACTINO SIGNATURE CERTINES 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 CAUFOIWIAI�.' THIS�APPLICANT MUST CALL N MORINS IN ADVANCE FOR ALL REQUIRED INSSP[COTNOINNSS-A/TT Ut0bI 4141104b422. PL 422. COMPLETE DRAWING AT LOWER AREA PINOVIDED. E 'I BIErcd X x 4 Till. PP/w/ l/U.&gli r D.,. 23 12tf Jb PLOT PUN (Dr..Y He Scelel Soals 'to e 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 OISMSAL BYSTEMB. 3. DIMENSIONED OUTLINED AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY R. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. d x r VCU Ch�vc� 6) � s rN Cows trY dub glad DMET USE ONLY Application Acceptetl BY DA ,/ � o. 7--L G/ 2 G�om Impmtlon By Data Pump 1n.pactlen BY Date DstrwUen In.vantlo-n�BY-` �LDat. C.mm w Pcfan>S ci��- r �{Fst-It W U^K LA Lop -6L-,, l_,, ACCOUNTING ONLY: AID/ FACT PE CODES FEE INFO AMOUNT REMITTED CHECKIICASH RECEIVED BY DATE PETMMITISERVICE REQUEST NUMBER INVOICE jb 2tk (a I 122�� b l l 2-4 "