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APPLICATION FOR WELLIPUMP`PERMIT �� ` +SAN JOAQUIN COUNTY PUBLIC HEALTH SEA VI ENVIRONMENTAL HEALTH DIVISION I� I P.O. BOX 388, 304 EAST WEBER AVENUE, S'MCKMN, CA Mum (2091468.3420 I� H4k•REFIfRRABt#PERMIT EXPIA#S 1 YEAR FROM DATE ISSUED [ComPMth In TrTplirats} # Y FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORk DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNT JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1 115.3 AND THE STANDARDS OF BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ' I JOB ADDRESSOR AIN# - I CITY Stockton PARCEL SIZE/AIN# oYyNER'BNAME Union ICs CO. -4 ADDRESS 6 1 0 0 E. .S h i e l a St. LA PHONE _ 8 corrTRAcroR J hn Sarmiento & Assoc. A ADDRESS PO Bx 54� Menlo uc# SUR coNr _F,92722 PHONE Erd�49CONTRACTORADDRESSd �� Park Llc#� PHONE# I} Ih TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# 41 '� ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL (TYPE OF PUMP► ❑Now 13RePelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL d t; ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# � ❑ SOIL BORING e a ®DESTRUCTION: �. Ih INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �{ (� A 13 INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATIONS PP _j.�tii t•,IlprYTy o. SOF CONDUCTOR CASING � 11DOMESTIC/PRIVATE 13 GDRAVEL PACK/SIZE TYPE OF CASING/STEELMVC II �' DIA.OF WELL CASINO p ❑ PUBLICJMUNICEPAL 13 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY �� 16 GROUT BRAND NAME E 9 MONITORING GROLTBEALRIMPED: 11 Yea ❑Ne 'F � �� CONCRETE PEDESTAL BY DRILLER:❑Yea ❑Ne _ 5 APPROX.DEPTH LOCKING CHESTER BO%!STOVE PIPE S PROPOSED CONSTRUCTIONMAILLINQ METHOD: MVD ROTARY AIR ROTARY AUGER I� k CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN 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,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN•a COMPENSATION LAWS OF CALIFORNIA.' TH APPU� T MU CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT I208)46ti4423. COMPLETE DRAWING AT LOWER AREA PROVIDED. t� q Signed X -Title1��/'✓Ott/fes i� Date PLOT PLAN[draw to Goals)Bwle 'to `II 1. N ES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE 2. SYSTEM OR PROPOSED } 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. E%PTE ANSION OF SEWAGE DISPOSAL BYeMS. . 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. ONIITHE PROPERTY OR ADJOINING PROPERTY. _ ..:..........: . _ y� *r I L ' M SEE ATTACHED- LOCATION :. :... _ ........... it i} .:...... .. . .. . : 1 „ ..... . i i� - i E .... .. ...... ..,..:. . .... ..., ..,,, ..... .. ., ., ., .. II 4f . Il 1 11 1 1� p I �I DEPARTMENT UBE ONLY Application Accepted By - � _ .. .. '`• `_": .�.'K --�.'...1,..= Date � Aran Grout Inspection By Date Pwnp Inspection By I! ,j Data Destruction Intpectlon By `.I I� Date Comments: VIM 0 5 'I VaILLA 0AL C� L n ( - ACCOUNTING ONLY: AID# FACT !`-'• E CODES FEE 1NFO AMOUNT REMITTED CHECKIICASH RECEIVED BY DATE !k I PPEIRMIMSEIRVICE REQUEST NUMBER INVOICE a 3. Ilb6 i