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_ APPLICATION FOR WELLIPUMP PERMIT Ted Alort:v a-d SAN JOAQUIN COUNTY PUBLIC HEALTH SERVILco ENVIRONMENTAL HEALTH DIVISION rq,pu Y1r�p P.O. BOX 988, 304 EAST WEBER AVENUE:, STOCKTON, CA VSMI- 88 (209) 408.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICOMpbta in Triplicate} APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN j JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADOREBS/OR APN* I CITY F-�!./ L _ __PARCEL SIZE/A U� OGL 4 oft/��tnui(rt!O, 150 PHOp� yy CONT �} .OWNEE 'Z.. N AD CONTRACTOR ADDREBB D• IJCf�"T 9�8�NPHOM I_ (P7 /L 9 BUB CONTRACTOR ( 2 G Er-GJ ADDRESS$!&—/V/V ae S-T— _L1Gt2722:zz PHONE a1' TYPE OF WELLMUMPZ NEW WELL ❑ REPLACEMENT WELL ❑ MDNIYORING WELL R ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROS&CONNECT REPAIR ❑ VAPOR EXTRACTIONN�WELL J New©Repair H.P. -!z DEPTH PUMP SETLOO FT. FIRST WATER LEVEL {TYPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL R ❑ SOIL BORING R ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO DO, 1 iff DOMESTIC/PRIVATE GRAVEL PACK/SIZE TYPE OF CASINGIST£EL/PVC DIA.OF WELL CASING " T22 D ❑ PUBLIC/MUNIMPAL ❑DRIVEN DEPTH OF OROVT SEAL,I SPECIFICATION R� ❑ IRRIGATIONlAO ❑OTHER GROUT SEAL INSTALLED BY V GROUT BRAND NAME<&ly L.yt�, E ❑ MONITORING t {TROUT SEAL PUMPED:)iL . [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr ❑No S� APPROX,DEPTH alc LOCKING CHESTER BOXIBTOVE PIPE PROPOSED CONfTRUCTONR]ILIWNO METHOD; MUD ROTARY AIR ROTARY AVOER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND k REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH k 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 I 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.' THE APFUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQWREO INSPEC170Ne AT 11tH)4pJr111. COMPLETE DRAWING AT LOWER AREA PRO DED, dLAAAA�Sr" \ Tltle� _� .._,_...._.__ Pate PLOT PLAN{Draw to Seelel Style 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPO BED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. 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, ... q r1��^" .. .. d�f :. l ... ...... .. - G I , .. .. ...: air -- L .. . . ... P *i smr .... ..... . . ...... .. . ASR 16 'UBLIC HFAi {�{ t r f`IV(NONMEN.TA�,. jCV, ..... . .. .;. HE LTH- D . . .. -. DEPARTMENT USE ONLY Applioatlon Accepted By / ' n Date Area Grout Irnpectlon By Date r!f 7 pump trmpectlon By Date Destruetlon Irapectlon By Date Comments: ACCOUNTINO ONLY: AID# FAC* PE CODES FEE INFO AMOUNT REMITTED HECK/ ASH RECEIVED BY DATE PERMITISUMCE REQUEST NUMBER INVOICE L-f 6w 73 1-5-