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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVI ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST, STOCKTON, CA 96201.388 (209) 468.3420 MOM-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complatf in Tripl"tel APPLICATION 16 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 JOAQUIN COUNTY DEVELOPMENTTITLE,`CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVrISION. roPN JOB ADDRES5R AN y 7 y I[V��S �'� l _�Q� CITY CL:" .. ._PARCEL SIZE/APNM 1O,000 'Z OWNER'S NAME E Y•' IQ_S ., ADDRESS 11277 Re)h; .VU"l l'!-}_{f� !r"pl�p1,lONEN�� 1535-.053(0 I CONTRACTOR S m}-}h` 'e n V l 1('Q n Iry�s y��-,X 6 ADDRESS I d Ce Ft1 i C#_570301 PHONE# 77 577—7 f 7-� - iI d SUB CONTRACTOR I,J 'If kJ1�t t�, i ADDRESS .0 V' 'Il LIC#-710( F D PHONE N7o) lq-Z$15 TYPE OF WELL/PUMP: NEW WELL ❑ REPLACEMENT WELL MONITORING WELL# 3. _ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL J x ❑New❑Rq lr H.P. DEPTH PUMP 6ET FT. FIRST WATER LEVEL p (TYPE OF PUMP) ` 13 OUT-OF-SERVICE WELL ❑ GEIOPHYSICAL WELL# BOIL BORING—7— 5 ❑DESTRUCTION: it - INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSd I '° "' A i ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION L3 1+�1�!1r1 DIA.OF CONDUCTOR CASING ` p F 13 DOMESTICIPRIVATE 11 GRAVEL PACKISIZE TYPE OF CASINGtSTEELlPVC G DIA.OF WELL CASING Z l ny� _ O 1 13PUBLICfMUNICIPAL 11 DRIVEN DEPTH OF GAOUT SEAL -F,, '''•t• SPEC!FICATION - LS+l�.V It HO ^_ R `f .p❑(IRRIGATtON1AG OTHER GROUT SEAL INSTALLED BY V t W GROUT BRAND NAME p-t C {,e E i (C�MONITOPoNG I GROUT SEAL PUMPED: Ely. ❑No CONCRETE PEDESTAL BY DRILLER:❑Yes CrNo S APPROX.DEPTH _- �r LOCKING CHESTER BOXISTOVE PIPEwLk3-(?—c wJj&cAYLq jA UQ- S PROPOSED CONSTRUCT'IONIMILUNG METHOD: MUD ROTARY AIR ROTARY�i AUGER CABLE OTHER (, I HEREBY 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 REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTFtACTOR'8 HIRING OR SUB-CONTRACTING 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'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL"REGUIRED-INSPECTIONS AT(2041114694422. COMPLETE DRAWING AT LOWER AREA'PROVIIDDED. --- Signed% ,� -P E.`#Clt741Ia Tltle _Pr66—f' S{f j7( 'yI SL31 PLOT PLAN(Drew to Scale)sole I L'to `Z S f 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED E 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 .. �' T - 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. 1 I APPROXIMATE ... WE5T GRANT'L1NE ROAD EXTENT OF CANOPY MOTORCYCLE EDGE OF ASPHALT REPAIR SHOP Q isi, i 392TD8-O3 ); 1 L ;- r FJP210,55-0-9 m 92108--0.9 FORMER -_ — — GASOLINE — USTS 1 APPROXIMATE 392108-01 LOCATION OF FORMER WASTE ` .. T OIL UST ... (392108=04)' „ • . . ... ..... " ' DEPARTMENT USE ONLY _ Appllmdo;.Accepted By fl.. - Dote I Arm ✓��. it Grout Inspection By ,F Date Pump irwpectio BY Oota Destruction Impection By -Date cemmenu' 1 ACCOUNTING ONLY: ,+ AIDN TAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#lCABH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 5 0 17 LEI, PVT337 ----------------- ld II