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\ APPLICATION FOR WELLIPUMP PERMIT PAYMENT >� SAN JOAQUIN COUNTY PUBLIC HEALTH SERVmV3 ENVIRONMENTAL HEALTH DIVISION I Elva 0'0' BOX 988, 304 EAST WEBER AVENUE, STOCKTON, CA 9MIW W Y 9 B 19A6 (209) 468-3420 BL JGI' 01ulN f�411.1N NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED BLi�HV��`Lfi�lr�ySk{akVl��5 ','•`• FII ?_� cl APPLIc _ �1 R€ 4114Fr�,•tfEkB'F "S lr 'IV1�14N (GamPIEts IB Triplicate) A JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIANCE WT11 BAN JOA IN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRON MEMA Is DIVISION. B ADDRESSOR APN# Illir? L I( 1'f( }-2£C� CIPN TRFI,CY � (( TY CA PARCEL SIZE/AI OWNER'S NAME ��> V V'L ELKIG CQ a•�• CA sry ADDRESS '� 1$ PHONE 141 I� -- ADDRESS coNrRAcro9il�+)lr - P„ull�pn,-^t �� i vrza Ce „TfdcIA�ORi•,e..S C _ LIC# cPHONE F�tOq)92�-C 7S$ SUBCONTRACTOR 1'JI''T2Grn,• F +U 2 JMF l�J1 ADDRF8631'00 Lllil, (4 uCoQLf60I PHONE(x/�12J?'4bul TYPE OF WELVPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELLe ❑Nen❑Repar N.P. DEPTH PUMP SETFT. FIRST WATER LEVEL 0 r TYPE OF PUMP) — ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# SOIL BORING a El DESTRUCTION: -0PHY INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO 0 1 ❑ DOMESTICUPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELPVC DIA.OF WELL CASINO 0 ` ❑ PJLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R C( ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED�y BYCMI'Nx".CTO R GROUT BRAND NAME E i ❑ MONITORING GROUT SEAL PIIMPEO:JAY. ❑No CONCRETE PEDESTAL BY DRILLER:❑YM ❑Ne S 'i APPROX.DEPTH �1,-ZZ f LE.i LOCKING CHESTER BOX/STOVE PIPE T. ` b. d PROPOSED CONSTRUCTIONI AILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHERL]L4C C'ILSL-� 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN 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 WOOL FORWHIOH 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 IB ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMI EIRIAT10N LAWS OF CAUFORy\IA'-�� APPLIC yT MUSyp#LL HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(S )4p- 22. COMPLETE DRAWING AT LOWER AREA PPOVIOF0. slar.d x \, 6 l �-'- Till. C'!�.03'E.cT ANfaG L2. on. S' 2-L�La PLOT PIAN I": to 6..1e)6eAl.�/'to 100 I 1. NAMES STREETS OR ROAD.NEAREST TO OR 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. L 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WRININ RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING FROPERrY. a¢"n '� ire • � I , N T 14- IT o- i l i J 7 6r,..a.z-•1 Jl M¢n ',; j �wt�w J.� ---------------------- 11 1 z„ ,.<a=etl,�r. l _ — O Proposed Boring Location ® Proposed GW Monitoring We!I sf L ------- DEPARTMENT USE ONLY Application Accepted By_;�Iy[�VL VV' 1 O.teAt. G'pw Impepll.n BY Y - Dae Pump Inep«tlon By Dae D-tr.tlen 1n.poction BY D.te �ommanU: A ...NTINO ONLY: AID# FAC# PE CODFA FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PDOAITMIMVICE REQUEAT NUMBER INVOICE Da c) tr C7 a L