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APPLICATION FOR WELLIPUMP PERMIT " SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 988, 304 EAST WEBER AVENUE, STOCKTON. CA 95201 388 1209) 468.3420 I ?? NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l ICemplatb In TTlpli$BTel ` - APPLICATION I$HERE BY MADE TO THE',SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1116.3 AND THE STANDARDS OF SAN JOAQUIN CO NTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB AODRES810R APNI CITY /' � PA EL zHT0E',f__%f2_: OWNER'S NAME r ADDRESS I S .+1 M1 QA+V •moi/ Q CONTRACTOR S ADDRESS C•$°�! LSI PHONE M SUS CONTRACTOR 'I � y ADDRESS UCC PHONE a I NPS OF WFLLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ 13OTHER l]. ❑ INSTALLA ION ❑ WELL SYSTEM REPAIR ❑ CR088-CONNECT REPAIR ❑ VAPOR EXTRACTION WELT I �r/s J ❑ New G Rep■Ir H.P. DEPTH PUMP 8177 FT, RIPE OF PUMP) FIRST WATER LEVEL O ❑ OUT-OF-SERVICE WELL - ❑ GEOPHYSICAL WELL I ❑ SOIL BORING 9 ❑DESTRUCTION- �` t, INTED�Ui TYPE OF WELL CONSTRUCTION 41MCIFICATIONS ! INiXI OUSTRIAL ❑OPEN BOTTOMA�.r DIA.OF WELL EXCAVATION ❑ DOMESTICMR IVATE 13 GRAVEL Of CONDUCTOR CASING D6 GRAVEL(PACK/SIZE TYPE OF CASING/STEEL/PVC (.II 1:1PUBUCIMUNICIPAL ❑DRIVEN ' DIA,OF WELL CASING lIi D DEPTH OF GROUT SEAL SPECIFICATION - D 1 ❑ IG IRRATION/AG 13 OTHER GROUT SEAL INSTALLED BY , 11MONITORING GROUT BRAND NAME E GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER,❑Vas ❑Ne 3 i APPROX.DE'fTN LOCKING CHESTER BOXISTOVE PIPE �3 PROPOSED CONSTIIIICTIONIDISRUS NO METHOD: MUD ROTARY AIR ROTARY AUGER1-N CABLE OTHER 1 HEREBY CERTIFY T HAVE PREPARED THIS APRJCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAW8,AND RULES REGULATIONS E B AQUIN COUNTY. HOME O R LICENSED AGENT'S SIGNATURE CERTIFIES THE POLLOVANG:•I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHIC THIS PERMIT 168UED,I$H NOT,EMPLOY. , S 8J T TO WORKMAN?S COMPENSATION LAW$OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES• THE FOLLO NO: •1 CERTTI HAT IN E F R WHICH THIS RMIT 1$ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WNORgMAN'S COMPENSATION LAW$ORJ CAUFO A.• T MUST - NCE FOR ALL REDLINED RNi TIONS At 44271. COMPLETE DRAWING AT LOWER AREA PROVIDED. Synod X d Title Z Dae■ PLOT PLAN{Draw to Seale)Basls .•to I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. <. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED Y. OUTLINE OF THE PROPERTY,GIVING DOMENS40NO AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. y. 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. i ... .`.. 9 ;.., I Aft . .. .. ....................... .......... .......... ...... ............ ......... ........ ...... :.. :... c.3 .... ... .. AV ... .. _ J-1N ivV� SERV. , � LIC HEALfiy RO,UNIENTRL HEAT ThLE)I/1510f, _� .. �.-DEPARTMENTUSE ONiT•+�sw ---'� "�^ Appllestton Aoeapted By Dets Ara■ V Great Iropxttan By Data Pump Inspection By Do i Destruction Inspeutlen By bete — Comments: JL r ACCOUNTING O Y: MDI FAG/ PE CODES F AMOUNT REMITTED CHE /C RECEIVED BY DATE P6WBTIAE RVICE REQUEST NUMBUt INVOICE I 79 8R2 3