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APPLICATION FOR WELLIPUMP PERMIT -M/ SAN JOAGUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCXTON, CA 96201388 I� (209( 4883420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICfmplftf M TTipUfftf) APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WOW DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH BAN JOAQUIN COUNTY DEVELOPMEM TITLE,CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. A v�d.2 v. Nr.LJ c ,X5§-z&o-l3 Joe ADDIIEBH/OR APN# �S��.-/}ST S 1lYYF. .'C',.�AT.S 3L` m =1!2127nA- s.r.F/ !moi PARCEL BIZE/gAPNI L7E0,l1-r- L3tJ/�7Ti ADDRESS Pa gvX 269 V,0,y4zFf,GA- vz jF09N 1 OW11EA'B NAME q 15 e Z CONTRACTOR ADDRESS PHONE# BUB CONTRACTOR ADDRESS Pl}'RK AN41y1::7 UU PHONE# TYPE OF WELI/PUMP: ❑ NEW WELL 11REPLACEMEM WELL ❑ MONITORING WELL# 13OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL i J ❑N*N❑R.p.S N.P. DEPTH RUMP SET—FT. FIRST WATER LLVEL 0 (TYPE OF FUMP ❑ OUTOFSERVIOE WELL ❑ GEOPHYSICAL WELL• soa BORING e ❑DESTRUCTION: 6 EQ SE� INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION Z j:L4 N DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELJPVC A/FF DIA.OF WELL CASING D ❑ PUBLICP UNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION Al ❑ IRIUGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Ya T •e CONCRETE PEDESTAL BY DRILLFR:❑Yw ❑Ne S APIAOX.DEPTH LOCKING CHESTER BOX/STOVE RPE S AROPOfEO CONSTRUCTIONIORIWNG METHOD: MUD ROTARY AIR NOTARY AUGER CABLE OTHER Qj Xe4r ,O✓J%f I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND C REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH CJ THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SU"ONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:/1 I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' PUCANT NOWT CALL M 11011118 IN ADVANCE FOR ALL REGUREO INfPECT10Mf AT 13081 fN-lb3f. COMPLETE DRAWING AT LOWER AREA PROVIDED. 61,,-1,X TIG.�/C4-rEGr ��G7L/JT D.'. PLOT PLAN ID1.W to S .l S..H W 1. NA S OF STREETS OR ROADS NE EST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED Z. O UNE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 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. 141 - 1 fc�3 L3 U1/h d.4 L= 1► 4 p DEPARTMENT USE ONLY Appliutlen Aeaep[eJ BY `� D.ta Are. GIaA B, I Iropectien NAMAl&iV D.1 Pump Imp don BY Dete Oslluc(ien Impction BY / DR. WLA44 -L :c LA)d7- ACCOUNTING ONLY: AID# FACE PE CODE{ FEE INFO AMOUNT REMITTED CHEC"ICASH I RECEIVED BY DATIF PERMITISERVICE REGUEST NUMBER INVOICE S D 0 0-3