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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERI._ES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 368, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED t9'�� ,OT ..0�� / � (Complete in DiOliuu) APPLICATION IS NE BY MADE TO THE 00.0111 O MR TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELO ENT TIT,kE�Aq�1�.�Y�,JP.ERA9,-1111,5.13 AND THE STANDARDS(JpF SAN JOAQUIN COUNTY PUr-OM HEALTH SERVICES,ENVIRONMENTAL HEALTH DWISION. y.�. JOB ADDRESS/OR Apt# W �*,(t I Lt(,H[al L 8%3 L.II / I/I IDN R-Y�.y �C �1 PARCEL SIZE/APNI � AC i- OWNER'S NAME 011T-- OF —1_r-ACL7 ADDRESS 1 FIa'L�Ci1:M 44MA-- PHONE CONTRACTOR ��C�FY��I"r LOW-, rr``M '�/�{� + , ) ADDRESS >��Me PHONE# '-I SUB CONTRACTOR 'PPf<,I rl G w�L ,DPI W I I (7I ADDRESS i� C YJ .L�C 'PTIoVICk L EUI b&Z L !(�Io [ !•✓rKl.iru TYPE OF WELL/PUMP: NEW WELL ElREPLACEMENT WELL ❑ MONITORING WELL k ❑ OTHER A,INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR EXTRACTION WELL Y J ` eJ1 Na6if S1 F31..tNaw❑R.air H.P. DEPFH PUMP SI FIRST WATER LEVEL O C RYPE OF PUMP) ❑ 0UT-0FSERVICE WELL ❑ GEOPHYSICAL WELL. ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS JI A U �INDUG'TRIAL ❑OPEN BOTTOM 1i DIA.OF WELL EXCAVATION ) DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE GRAVEL PACK/SIZE )� TYPE OF CASING/STEEVPVC DIA.OF WELL CASING �.�l9tt O 11PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL O y SPECIFICATION iRySZ/Y1 F—40D R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY L b GROUT BRAND NAME E r ❑ MONITORING / GROUT SEAL PUMPED: 4Y. ❑No CONCRETE PEDESTAL BY DRILLER:❑Y. No B s APPROX.DEPTH \�Y'!/ LOCKING CHESTER Si RPE B .I PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER s 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 ANO I REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRM INSPECTIONS AT I20S14S111 2n. COMPLETE DRAWING AT LOWER AREA PROVIDED. M sionX �' — Title JL-"V&VZ — PJ4W hl G PLOT PIAN IDraw to Sool.l Sul. 'ea 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERFY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTUNF.S 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 WAL(S. ON THE PROPERTY OR ADJOINING PROPERTY. 11Ju r-- p \ J G—I v ri #� NT � P, rt ^ 6 SAN JOAQL C" i PUBLIC HEALI I Tf2Avl 5S ,:-g ��Z ' ENVIRONMENTAL HEALTr� S T-frj-1L)Aj —^ 0111FIcJi, II DEPARTMENT USE ONLY Application A.aaplM By Data out Inapnction By Data Pump Inap"Ilon BY / Data 7 -Z1v'.VS D.trmtbn Inop�a niicn By Data Comment.: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHEC MASH REC6Vm BY I DATE PERMITISERVICE REQUEST NUMBER INVOICE 55a 0 X33 -777 3 4 5 - 0 '3 5 314