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q APPLICATION FOR WELLIPUMP PERMIT j SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST, STOCKTON, CA 95201-388 �(/N (209) 488.3420 Q 8 , o MOM-REFUNDABLE PERMIT EXPIRES 1 TEAR FRONT DATE ISSUED 1995 (Complete in Trvlwte) MvT/ NT APPLICATION IS HERE BY MADE 70 THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION I€ I NCE WITk BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEAt JOB ADDRESSOR APN# 2- �`jD>W 24jP0 S CITY2_�� PARCEL 91ZE7APN:1' OWNER'S NAME N(T- '�. ADDRESS .'2— 157•�45Z, s, r !/L'JIAC !?E`•' SM xPHONE i CONTRACTOR ADDRESS /9d (= A/ PHONEJA /•�� '. BUB CONTRACTOR /L6 ADDRESB,1r 7VWC -- PLUM# &J/2 2!�PHONE TYPE OF WEU-tPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL R ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL A J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O - fTYPE OF PUMP) . ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# SOIL BOiRING ❑DESTRUCTION: 'C .re ,nom -i INTENDED USE TYPE OF WELL �� CONSTRUCTION SPECIFICATIONS 'i A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASfN�O. 1,4 p ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING /✓�� A ' .i 11PUBLICIMUNICIPAL [3 DRIVEN DEPTH OF GROUT SEAL ,,ma�yy,� SPECIFICATION _ R 13IRRIGATION/AG E3 OTHER GROUT SEAL INSTALLED BY !�/�/I� GROUT BRAND NAME E - ❑ MONITORING / GROUT SEAL PUMPED: ❑Yea Na CONCRETE PEDESTAL BY DRILLER:❑Yep ❑No S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PPE PROPOSED CONSTRUCTIONIDRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER i 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 k THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORIGNAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFO NCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN-6 COMPENSATION LAWS OF CAUFO TH ��DVANCE FOR ALL REDIA TI`ONS�AT(200)468-2423, COMPLETE DRAWING AT LOWER AREA PROVIDED., 1 slpnee X Thle#'�V f PLOT PIAN IDraw to SeNal Soala "to 1, NAMES OF STREETS OR ROADS NEAREST TO 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. I(` 3, 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. ......... ............ ..... ....... .................... .. ...... .... ...... .. . t I . ....... y .. � 3 195 ,1'U 1� :.... . ..... �.: Ing � T BLfC HEALTH.S RuICE :.. .. �1IS1 �! A TH, DEPARTMENT USE ONLY �k fI�J`� Appiieatlen Aeceptad BY Data � 3 Area�` 1 ih Grout IMOPtKtlon Sy Date Pump Impaction By Data Deatruetlon Inspection By ate i $- - Commaft; ACCOUNTING ONLY: AID! FAC# D . PE CODES FEE INFO AMOUNT RENUTTED EC !CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE o - 00 c 0-245 PS— RECEIVED i I,L c rCyi.� ��its Pc !'... SAN ,10