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APPLICATION FOR WELLIPUMP PERMIT AN JOADUI' INTY PUBLIC HEALTH SERVIL. ENVIRbWNTAL HEALTH DIVISION v� P 0 BOX 388,446 N.SAN JOAQUIN ST., STOCKTON,CA 96201.388 (209)468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APPLICATION ISHERE MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO (Complete ANDIOA INSTALL THE WORK DESCRIBED.THIS APPLICATION 1S MADE IN COMPUANCE WITH SAN IS JOAQUIN COURT'S DEDEVELOPMENTTITLE.CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNf y ! t It/hLLh� CITY-7-m t q�J PARCEL&2FJAPNS OWNER'S NAMELI �. Iw 1� ADDRE6S [/� ��' CO ), PHONE f CONTRACTOR-,* eL1.�1.1�LA.Te(,� �� IC_. ADDRESS TTT� u 11Y -J{ �' llf PHGNE.�ID�337ff730 SUB CONTRACTOR EjITL[ .t I D16 1j;n c� hv,nM rne,,�,/,,..(,ADDRESSPO Ch D LICE PHONE ij&162 1 V$jr TYPE OF WELUPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑ NITORINO WELL f 11INSTALLATION 11WELL Sy6TEM REPAIR ❑CMOOTHERROSSCONNECT REPAIR VAPOR EXTAACT16N WELL 13 Now❑RaPalf H-P. DEPTH PUMP SET FT, FIRST WATER LEVEL (TYPE OF PUMP) �. O ❑ ❑DESTRUCTION: OUT-0F-SERVICE WELL 11GEOPHYSICAL WELL IF 11SOIL RORING e IN MED USE TYPE OF WELL CONSTRUCTION."""TIONS J ❑INDUSTRIAL 13OPEN BOTTOM DIA•OF WELL EXCAVATION- �h (� Dlq,OF CONDUCTOR CASING N� A ❑DOMESTICMRIVATE GW RAVEL PACK/SIZE .6 7-0 TYPE OF CASING/STEEUC_ 2 rV�• DIA.OF WELL CASING Z D ❑PUBUC/MUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL �. I / SPECIFICATION D T❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY I I V GROUT BRAND NAME E {L1 MONITORING �j GROUT SEAL PIMPED:❑Yae RNo CONCRETE PEDESTAL BY IINLLER:�yr ON. 5 APPROX.DEPTH `5 LOCKING<HE6TER (STOVE RPE S PROPOSED CONSTRIICTION/dtlWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I NE9EBV CERTIFY THAT I 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 SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'t CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE POLLOWINO: '1 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 CAUFORML THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED SPEC TIONS AT I2G91"po-3423-COMPLETE DRAWING AT LOWER AREA PROVIDED. I SlprrdX TIpaI e E. f�rAAAC. ! Dote z1 } PAT PLAN 4D,—to S.M.)6-1. •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 OUTUNFS 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. bJc 6.1 ��-- les- DEPARTMENT USE ONLY Application Accepted By Date Area Grout Irep tion By Data pt—P Inpwtlon By vete Dntructlan I-paeti—By Dab Comrn w ACCOUNTING ONLY: AIDS FAC. PE CODED FEE INFO AMOUNT ADMITTED CHECK//CASH RECEIVED SY DATE PEPAQT/SERVICE REQUEST NUMBER INVOICE