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APPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVIL ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N, SAN JOAOUIN ST', STOCKTON, CA 95201 -388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ; (ComPMu in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/Olt INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY WBUC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. CITY S+o CX40n PARCEL SIZVAPN6 JOB ADDRESSMR APNM I L� - Q -1 ADDRESS I I ��`n �/ I Ern Ii-Y // 1 /P HCl PHONE N "s( Y �/UyJ_ OWNER'S RIMAE r �<�+''�� II � 5i j Fy1 V j lrr, to Nn a f1 -CO.,I ADDRESS 1710 {Mal 11 5Y EY61017_ LIC# PHONE • 8 - 705 CONTRACTOR 'Y1 SUB coNTRAcroR ADDRESS 'Z3iSL'y1��1�4� Wa�J �+ i4'lucN SIZUB PHONEN C �$ �I � TYPE OF yJELLJPIIMP: 1�{L NEW WELL ❑ REPLACEMENT WELL JLY MONITORING WELL l�=LfIl ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CMSS{ONNECT REPAIR ❑ VAPOHEKTRACTIONWELL # J ❑ Now ❑ Pecalr X.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ITYPEOF WMPI ❑ OUT-0FSERVICEWELL ❑ GEOPHYSICAL WELL # ❑ BOIL BORING R 1 1.. ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CON6igUCT10N SPECIFICATIONS it A ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING D ❑ DDMESTICIPNVATE GRAVEL PACKISQE _ TYPE OF CASINGISTEEROL C X.It Ln� PUC. DIA. OF WELL CASING 11 ��zill X4O 4" ❑ DEPTH OF GUT SEAL Z Tf SPECIFICATION '��V1 0 R PUBLICIMUNICIPAL ❑ DmVEN �-y GROUT SEAL INSTALLED By r'TDGL;trU " GROUT BRAND NAME E ❑ IRRIGATIONIAG l]O OTHER GROUT SEAL PLIMPED: ❑ Ys ONO CONCRETE PEDESTAL BY DRILLER: ❑ Ys ONO S MONITORING LJ S APPROX. DEPTX ) LOCKING CHESTER BOIUSTOVE RPE e AUGER CABLE OTHER PROPOSED CONSTRUCTIONIDW WNG METHOD: MUD ROTARY AIR ROTARY I HEPEBV CERTIFY THAT 1 HAVE PREPARED THIS APftLLATION AND THAT THE WOW( WILL BE DONE IN ACCORDANCE WITANH SJOAOUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND y . REOUTATIONS OF THE SAN JOAOUIN COUNTY. NOME OWNEfl OR LICENSED AOENT'S eIGNATUPE CERTIFIES THE FOLLOVANG: 'I CERTIFY THAT IN THE NG OR SUEF NTRACMANCE IN THEWOWEOR WHICH V THIS PERMITIS I66UED, I6HALL NOT EMPLOY PER60N66UBJECTTO WORKMAN'S COMPFN6ATON lAW60F CALIFORNIA.' CONTRACTOR'S HIWIECTTO B{ONTRAS SIGNATURE CERTIFIES THE FOLLOWING: ' I CEREIFY TNAT IN THE PERFORMMILE OF THE WDRK FOR WHICH THIS PERMIT I6166UE0. I SHALL EMPLOY PERSONS SUBJECT TO ER AMA PROVIDED.COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MW�T7CALL 241Mllllle IN ADVANCE EOR ALL REDUq® INBPECTION6 AT�3433. COMPLETE DRAWING AT LOWER AREA P�DED smnsdx ^ �• ^^ .vt , f-vhwvt�Ll✓/ rin<�r'Od f.C � QQ //�� JOPI^ V15or oae ifOT5ula1 6ula�_ - to�V_ 4. LOCATION OF HOUSE SEWAGE dSPO6AL SYSTEM OR PROPOSED 1 . NAMES OF STREET60R ROADS NEAREST TO OR BOUNDING THE PROPERTY. ExppN610N OF SEWAGE DISPOSAL SYSTEMS. 2. OURINE OF THE PROPERTY, GIVING OIMEN6IONB AND NOflTN DIRECTION. 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. 1 3. DIMENSIONED OUTLINES AND LOCATION OF ALL E%ISTING AND PROPOSED ON THE PROPERTY OR ADJOINING PROPERTY. X { STRUCTURES, INCLUDING COVERED AREAS SUCH A6 PATIOS, DWVEWAYS, ANO WALKS, 1 , DEPARTMENT USE ONLY Appllstion Accepted By _ Dat Ars r Grote lrty Ylon By Date Pump Inspection By Date Dstrwtlon Inspection By atl A40" Date 1 L Comment: i ACCOUNTING ONLY: AID# FAC# FE CODES FEE INFO AMOUNT REMITTED CHECK)/CASH movEoY GATE PERMITISFRVI gEOU T. INVOICE Copy