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` APPLICATION FOR WELLIPUMP PERMIT J cl 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 ISSUED (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WORK DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIANCE WITH SAN JO'^'11N COUNTY DEVELOPMENT TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JC DDRESS/OR(APNR/ / 7 3 1.u, CJ✓1YL(JLJ-y Imo& CLTYGL o d i CA L. PARCEL SIZE/APN/ �ry C7 OWNER'S NAMES P�IV G�J2 I l/q/✓G k' YT�C ADDRESS J//7`/3 � l V/Z Al E r- RL Le J/ PHONE*AO•O/7 7_s- CONTRACTOR / / !"i/�'+ �o ADDRESS 61 VC S: CA t.ST' ..R-AiCCI/L.I j-i PLANEJ- SL ONTRACTOR GLC./, A% ' ,K Q ADDRESS-_7[A f-/O C k7 LJC 3 .a )9 PHONE/ 6 922— TYPE OF WELURIMP: 1I-L-L,NEW WELL ❑REPLACEMENT WELL ❑ MONRORING WELL/ ❑OTHER L ,Ea INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION•/WELLT J _ y!, L•1 N&W❑R.Pol, H.P.�� DEPTH PUMP SET�FT. FIRST WATER LEVEL T� O IT' OF PUMP) ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL/ ❑ BOIL BORING B ❑DESTRUCTION: IN DEB USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A J 111��DPWUSTRAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION / / DIA.OF CONDUCTOR CASING D t� VSOMESTIC/ VATE L]GRAVEL PACK/SIZE TYPE OF CASINGJSTEELB'VC VC_ DIA.OF WELL CASING //J D e 13 PUBLIC/MUNICIPAL 13DRIVEN DEPTH OF GROUT SEAL D / SPECIFICATION B 03'^JGATION/AG ❑OTHER GROUT SEAL INSTALLED BY P9 1'4 L 17 YL GROUT BRAND NAME gF'ti ro/v 7?�'E�d 1, EI7NRORING ry r GROUT SEAL PUMPED:❑Ym ❑No CONCRETE PEDESTAL BY DRILLER:❑Yoo [ No S S AP�X.DEPTH //•'J LOCKING CHESTER BOX/STOVE RPF S It PROPOSED CON{TRUCTIONMRIWNO METHOD: MUD ROTARY ✓ AIR ROTARY AUGER CABLE OTHER IH BY 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 AND A RE ATIONG OF THE JO UN COUNTY. HOME OWNER O LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TR ER IT 16165 NOT EMPLOY HOME 6 SUBJ O WORKMAN'S COMPFN6ATION)AWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFlES T_LLOWIN '1 C RTIFY T IN TH RF A OF HE THIS PERMIT IS ISSUED,I SHALL EMPLOY PLR60NS SUBJECT TO WORKMAN'{COMPEN{ATIOM UWS OF CALIFORNIAA.' C WT NC C Z4 A AFOR ALL REOIARm'`'I�N/{�PF�C�TI,O N�{AT 130{1 4{BJ1:LX.COMPLETE DRAWING AT LOWER AREA PROVIDE�Dj. r SID- X ✓ D.t. �� / y� PLOT PLAN IDL to S.W.)Su1e to 1. MES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 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 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. A� / �� 11 1996 N '06LW, HEAL F VITAL -1EALT} Imo-j� DEPARTMENT USE ONLY Appllutlpn Accepted By -z- G-1 Grpm Impemmn sy /t Dae `F /[ `i b Pump In.vemlon By wt{ .S•--t yG De: :tion Imp«tion BY DAte Cpnwrenb: :OUNTING ONLY:�j�� AID) FAG/ PE CODES F E 1NPO AMOUNT REMITTED CHEC I/CASH RECOVED BY DATE PERMIT/SERVICE REQUEST NUMBPA INVOICE IQL74 , 11 Of- 4 - s Q