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1• Mir M M M M M M wo ® M M M M Mir M § k r-.M=... 7-17, i s r�7777-s APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O, BOX 3W &A EAST WEBER AVENUE, STOCKTON, CA 95201388 12091 468 3420 NON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED THIS APPLICATION IS MADE IN COMPLIANCE WITH JOAQUIN COUNTY DEVELOPMENT TITLE CHAFFER 9 1 115 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DP41810N JOB ADDRESSOR APN# �/ I ? S f 1 CITY f "��t, PARCEL 9iZEJAPN# OWNER B NAME __ f _ c.r.. AZA C,, G', y � , I . � 1 � pm �1L�...�_.�r__„ ._..._ADDRESS � 7 PHONE r�l> Y77- CONTRACTOR, d/1 .!J Q^, c'I .t��_.... ADDRESs �7 liT✓v / v uce rf-6 170 PHONE/ ;�c 1- SUB CONTRACTOR F ADDRESS I, f C SSS4 - 19,� 3 J PHONE TYPE OF WELL/PUMP- ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL# %I+"W'f ) ` 113 OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CR08S-CONNECT REPAIR C3 VAPOR EXTRACTION WELL I 13 N.13Rapalr HP DEPTH PUMP SEF FT (TYPE OF PUMP1 FIRST WATER LEVEL r`L ❑ OUT-OF•SERVICE WELL ❑ GEOPHYSICAL WELL N ❑ SOIL BORING Nt' ❑DESTRUCTION INTENDED UVE TYPE OF WELL CONSTRUCTION EPECIFICATIONZ p 13 INDUSTRIAL ❑OPEN BOTTOM DIA OF WELL EXCAVATION O DIA OF CONDUCTOR CASING 19 ❑ DOMESTICIMVATE ❑GRAVEL PACKISIZE TYPE OF CASING/STEELIPVC_2_ 'yC - S c Y DIA OF WELL CASINO Z!' ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 0 9 Y a Cn S SPECIFICATION ❑ IRRIGATK)N/AG 13OTHER GROUT BEAL INSTALLED BY U t F I `,�S ,� r GROUT BRAND NAME RI MONITORING GROUT SEAL PUMPED ©Yr []No' No CONCRETE PEDESTAL BY DRILLER ❑Yr ❑No APPROX DEPTH G fc 3(1 e,-r Cu f LOCKING CHESTER BOX/STOVE PIPE PROPOSED CONSTRUCTION/DRILLING METHOD MUD ROTARY _AIR ROTARY AUGER^ �CABLE OTHER ,I HECIEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND TIZAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES STATE LAWS AND RULES f REGULATIONS OF THE SAN JOAQUIN COUNTY HOME OWNER OR LICENSED AGENT 8 SIGNATURE CERTIFIES THE FOLLOWING 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WH - - - -- _ THIS PERMIT 18 ISSUED,I$HALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN&COMPENSATION LAWS OF CALIFORNIA- CONTRACTOR S HIRING OR SUB-CONrWTING SIGNATURE CERTIF THE FOLLOWING 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN a COMPMSAT10N LAWS CALIFORNIA' T14E APPIJCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION&AT 120/1400-3423t COMPLETE DRAWING AT LOWER AREA PROVIDED Title__ .��P Z INS- •ES Det. 4 [7 P4.OT PLAN!Drew to Sora1 Scale t. I NAMES OF STREETS OR ROADS ST TO OR SOUNDING THE PROPERTY 4 LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR pRDpOSED 2 OUTLINE OF THE PRD AIV FMENS1068 AND NORTH DIRECTION EXPANSION OF SEWAGE DISPOSAL SYSTEMS 3 DIMENSIONED OUTUNFS 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 r Ila 6, DEPARTMENT USE ONLY ¢ Appllcstion Accepted By ( -/�Jyi�Q r' ��V Date Grout Inspection By Dote Pump Inspection By Dots Destruction Inspection By A-1 Date ! Comment, J a / �. f f�1 c-1 1 ACCOUNTING ONLY AID# FAC# , I PE CODES FEE INFO AMOUNT REMITTED CHECK#fCA&H RECEIVED BY DATE PEF MITISUMCE REQUEST NUMBER INVOICE s z*, r � ;