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or -A. APPLICATION FOR WELLIPUMP PERMIT AN JOAOU 1UNTY PUBLIC HEALTH SERVIL- 1111011111111 ENVIkiwMENTAL HEALTH DIVISION P 0 BOX 388, 445 N.SAN JOAQUIN ST.,STOCKTON,CA 95201.388 (209)468.3420 NON-REFUNDABLE PERMLT EXPIRES 1 YEAR FROM BATE ISSUED (Complete iR Triplicate) APPLICATION 16 HERE By MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK Df6CRIBEO.THIS APPLICATION l3 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, �CHAPTERS-111 5.3 AND THE STANDARDSOFSAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOR ADDRESSOR AP } CNI Wq/ ■Y L (' 7l 12ei t CITY Trn el/ r�.� PARCEL S12E1APN/ OWNER'S NAME/ yJTZ 1 1/1.., �� t-Z—— ADDRESS 1 ' N, b`'� � /P PHONE f �/� CONTRACTOR C.`eG.�'L tt�L/r �rT-V -�HC• ` , AODAE66 :tls Z' CLQ PHONE/�?'0.�37`d7.3d SUBCONTRACTOR 1 d � hV I YI x/11-- ADORES O3j �aQ IJGI 7 PHONE I7/ S /�✓1J TYPE OF WELLIPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELLS OTHER S LLE^C LJ.c/`�ti� ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION IELL I ✓ ❑New❑Flepalr H.P. DEPTH PUMP SET Fr. FIRST WATER LEVEL O ITYPE OF PUMP ❑OUT-OF-SERVICE WELL ❑GEORIVSICAL WELL X ❑ SOIL BORING S ❑DESTRUCTION: INTENDED USE TYPE Of WELL CONSTRUCTION SPECIFICATIONS J, A ❑INDUSTMAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑DOMESTICIPtIVATE GRAVEL PACKISIZE O.OzO TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D ❑PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL S I, SPECIFICATION R ❑IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME F MONITORING GROUT SEAL PIMPED;❑Vr a CONCRETE PEDESTAL BY DRILLER; Yr ❑Ne 5 APPROX.DEPTH LOCKING ESTER f6T0 VE R��P//E S, PROPOSED CONSTRUCTIONIDWLIINQ METHOD: MUD ROTARY AIR ROTARY AUGER GABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(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:"1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMITIS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLI NG: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALLEMPLOY PERSONS SUBJECT TO WOFA(MAWS COMPENSATION[AWS OF CALIFORN THE DCAN)f A�IUa 3A YIOUBE IN ADVANCE FOR ALL RfOUm PEC710NO Ay,1209)4443422.COMPLETE DRAWING AT LOWER AREA PROM OO.. /�r� Sleron x, /y//��G� )� __TItle I�_r ... Dets G L/< PLOT PLAN ID—to Sale]Sule Ie 1.NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING 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. J. DIMENSIONED OUTLINES 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. co CAI Wor DEPARTMENT USE ONLY �—yL APpllatlon Accepted By Data -3-✓1- 7,5 Arar 52 Gann Iropeoti-By Date Pump Iropedlon 13 Date Deetructkn Iropectlen By Date Cemmmte � ACCOUNTING ONLY: AIDR FAC• PE COO" FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE �t �� 33 -17