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APPLICATION FOR WELLIPUMP PERMIT ids a. SAN JOAQUIN COUNTY PUBLIC HEALTH SERI, ENVIRONMENTAL HEALTH DIVISION PAYMENT P,O, BOX 386, 904 EAST WEBER AVENUE, STOCKTON, CA 9MI,%% ��V�� 1209) 488.3420 DEC 14 105 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED SAN aM/:41)IN LSiJ NTY (Complete IG Triplicate) PUBLIC HtALIrl �It VICRs APPLICATION N HERE EL MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT 70 CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THI6��N��YNy��0ryBv1�ln�ryN��u� JOAQUIN COUNTY DEVELOPMENT TRIS,CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTALl1�EAL N p1 pry, AN JOB ADORE88/O APNI S G 9 CITY PARCEL SIZE/APNI p--� '7 OWNER'S NAME L.�/V U/�lW� V`^�,,�� ADDREBI /U(�` rn F� Vivi /� ( PHONE 493 --503Z- CONTRACTOR r �,J�I 'y.. ADDRESS 47 W'�" D , W�PHONE I Q .S}ZJ 41 i /� YYY-------�'--�.� {� SUBCONTRACTORS/cPY ADORES f Zy RHONE• ( TYPE OF WEUJPUMP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTON WELL I - J ❑N.❑Rgelr H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL D (TYPE OF RUMP( L�,/�1 ❑ OUT-0F-SERVICE WELL ❑ OEOPHYSICAL WELL# Il7�,A BORING S ' 11 DESTRUCTION: VVV �� INTENDED USE TYPE OF WELL CONSTRUCTION SPECIRCAT10N8 A ❑ INDUSTRIAL ❑OPENBOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/HTEFUWC DIA.OF WELL CASINO D ❑ RUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROW SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED By�C_ _. — GROUT BRAND NAME E ❑ MONITORING / GROUT SEAL PUMPED: ❑Ys [IN.. CONCRETE PEDESTAL BY DRILLER:❑Yr ❑No S APPROX.DEPTH I D l LOCKING CHESTER BOX/STOVE PPE _ 5 PROPOSED CONSTRUCTIOWDRILUNO METIIOD: MVD ROTARY AIR ROTARY AUGER CABLE OTHER Q(rlf� I HERESY 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 BAN JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I MALL HOT 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.' THEA CANT MMDDB CALL 24 LOURS IN ADVANCE FOR ALL REQUR I SPECTLONB T 12")�\N 44/M COMPLETE DRAWING AT LOWER AREA ROnVID , _ Bignell X THIaK1� /� ROT PLAN(Drew to Soelel Bole 1. NAMES OF STREETS OR ROADS 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 DISPOBAL SYSTEMS, O. 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. ell � o �, 1 , r _ l (� R OwMTMENT USE ONLY APpllcetlen Accepted By ,ylY/)VnYy/'AJ/II„PA_ /K/�O•��l^JYlltl�..- Bate Arw Grein Impectlpn BY Dtte Pump Sepectlon By Deb Deetr etlon Impwdon 8Y Deb (� n Commence: V" {/_` Y�V�'11 7 '.A \ \. V-(�/ WV <— L,L,r�� °L g-mU 41 ACCOUNTING ONLY: AID# FACS ' PE CODES FEE INFO AMOUNT REMITTED CHECKI/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE