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APPLICATION FOR WELLIPUMP PERMIT — SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDI$I AI ` ICompletn in Triplicate) [ p APRJCATION IS HERB BY MADE TO TME SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS AAFPI IMMRnADE WWWccctSMRtANC H SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY RIBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB AOOFESSKOR APNI 7735 S . RT 99 WEST FRONTAGEITYRD. STOCKTON PARCEL SIZE/APNI OWNER'S NAME DAVID RAKOVICH ADDRESS 5220 N . ASHLEY . ST-Qf KTOMONEI 952-3129 coNTNACToR HFNNINGS BROS- DRILLING CO. ADWSs 3525 RELANDALE.,B 290813I10NE, 545-1185 , SUBCONTRACTOR /q ADDRESS LICI PHONE TYPE OF WELM l/PUMP: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS{ONNECT REPAIR ❑ VAPOR EXTRACTION WELL 0 ✓ ❑N.0 Pop.1, H.P. DEPTH PUMP SET ff. FIRST WATER LEVEL O (TYPE OF PUMPI - 0OUT-0FBENVICE WELL ❑ GEOPHYSICAL WELL e ❑ 801E BORING e ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ` ❑ INDUSTRIAL 1p❑OPEN BOTTOM DIA.Of WELL EXCAVATION 2011 DIA.OF CONDUCTOR CASING O L ❑ DOMESTICIHOVATE RI GRAVEL PACKISIIE C TYPE OF CARING/BTEEIRVC P DIA.OF WELL CASING 1 0 11 D 0 ItALIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 100V SPECIFICATION RFNTONTTF R ry.A IRRIGATION/AG ❑OTHER SNOUT SEAL INSTALLED BY AJ TrHq E N N I.N G S GROUT BRAND NAME KIN. L ❑ MONITORING GROUT SEAL PU13Y. yO MPED: Y� N. CONCRETE PEDESTAL BY DRILLFR:❑Y.. N. S APPROX.DEPTH �O/ LOCKING CHESTER SO)/STOVE RPE 5 '— PROPOSED CON41FINCTION/ORLUNG METHOD: MUD ROTARY X AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT 1 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 SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR 61.8-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORWAM'S COMPENSATION LAWS OF CALIFORNIA.- THE APPIICAN"UST CALL M HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001480-7 2081 AM 2]. COMPLETE DRAWING AT LOWER AREA PROVIDED. NP �X 4mS�nL Y�H. R n m n 4 Eti�OIIt Q:s D.I. MAY 11 , 1995 RAT MN m,«+To SWaIBMI.�'tto I. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. I. LOCATION OF HOUSE SEWAGE DIBIOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,SPANS 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 fr. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. 1 F v I 1 M ILA LA vI r Y4 t �I .: pl rxl ( .� �L � ➢ z yT ww L, 4z d — m I OV p\ Q3m G CD m QI 1. Z y DEPARTMENT USE ONLY 1 MWl..tl.n AccT1eE B C' 0. 1L 1 jq /. o IRireom.BY Dot D.m<tl.,,1/.JJ 6oR BY '/ / ✓ D.t. Comm.rm:(O�d u��,y�✓,� /yrs: -'/r/��'fY.f�.//f�C�•K/I�IGT��3��d�i'60 fr ACCOUNTING ONLY: Al., FACT PE CODES FEE INFO AV...T RFMITTOO CHEC-ICASH RECDVEO BY DATE PFAMITI FRVIC UESTNUMBER INVOICE -3 S B 8