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APPLICATION FOR WELLIPUMP PERMIT SAN JOAO.UIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAOUIN ST., STOCKTON, CA 95201-388 (209) 469.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1Complots in Tdplierul APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-,11�15.3 AND THE STANDARDS OF SAN JOAQUIN COUNTYPUBLICHEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AODRESS/OR APN# O 1.+y11Isk CITY JTO L.k�O 1C� - PARCEL SIZEIAPN# +�a f � • Sc, w^L ADDRESS 1"500 PHONE#q,�p Ji7�0-kA 6 OWNER'S NAME 1 CONTRACTOR E M�r-O� — — ADDRESS143-3 N it 'Vka ll�{{•q CIC/►* p /'�PQRONE:�1bg2S-33oory� SUBCONTRACTOR ' ' ADDRESSf„0-�33�,RID I'S1.9uc*C5 v IOC#HoNEiF� ja3W a TYPE OF WELUPUMP:�NEW WELL REPLACEMENT WELL ❑ MONITORING WELL# 'L7�07HER '9If ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Repair H-P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS Q+f '4 ❑y INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 4S DIA.OF CONDUCTOR CASING lr A D LSF DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELIPVC NF1 41 7 P�Y—C� DIA.OF WELL CASING - D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ LRRIGATIONfAG 'tROTHER GROUT SEAL INSTALLED BY [` GROUT BRAND NAME Pa r � f ❑ NIONfTORING GROUT SEAL PUMPED:*51Yw ❑No CONCRETE PEDESTAL BY DRLLLFR:I.SLYaa 1114. S APPROX,DEPTH LOCKING CHESTER BOXISTOVEPIP/E S ` PROPOSED CON&TRUCTIONAMLLINO METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER I HEREBY 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:"I 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 FOLLOWING: "I 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 CALIFORNIA." TFI AA�iAN�ST CAl}rj4 OURS IN ADVANCE FOR ALL REQUIRED INSPECTION&AT 12091 4681433. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X_!� f/h/VL/ _ Title K� / Date U s w PLOT PLAN(Draw to Scale)Soak "Eo 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OA PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES 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. • .. . .... P YM RET MAY 15 ... .... ... ..JL1f1 �i�1 �f ttiJ�fj 117 C EAi 7�I �Lr 1JI:CES ENVIRONh ENTA 'ri,DIVISION --- Application Accepted By Data Grout Impaction By Date Pump Impaction By Date Dstruetlon Inspection By Date Comments: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE of