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APPLICATION FOR WELLIPUMP PERMIT %„J SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.386 (2091468-3429 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICgmplats in Tripligatal APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 15 MADE IN COMPLIANCE WFFH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN# Z CITY _ PARCEL SIZElAPN# carp % OWNER'S NAME L S ADDRESS-ZppiSS �.t1]LS.�J..� ��r► oPHOON`�0 qb CONTRACTOR Off'(' r 1�• �_ADORE551_fl33ia� �ID111g�o� LIC#jaj�S O1�PHIE,r 1O73��_�{�" SUB CONTRACTOR ADDRESS LICK PHONE N TYPEOF WEU,MUMP: XINEW WELL 1:1REPLACEMENT WELL MONITORING WELL it Mw 7 miN-6 ❑ OTHER IR IDS'aml, S 54 Jam} ❑ INSTALLATION ❑ WELL SYSTEM REPAIR 1:1 CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# 0 3b4 n donn.trt-�' 13 Now 13q MVV-2 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP] ❑ OUT-OFWELL, ❑ EOPHYSICAL WELL# ❑ SOIL BORING S �' a s �' tae b� p I 1 —LA �U f �e {i, �nlo�w-erL1 n� � �r�l o �tl w � 1'►ti{ DESTRUCTION: MW'1MW-2. � -m\,4--2- 5y 1�i Y, lyv� S e� ■ �s =�o�� -aS-.A INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION JC)t I DIA.OF CONDUCTOR CASING 12t/ rriw^7} D ❑ DOMESTIC1P vATE 10 GRAVEL PACKISIZE TYPE OF CASiNGISTEEL/PVC �t•Pit(-- DIA.OF WELL CASINO i1 D 13PUBUCIMUNICIPAL [3 DRIVEN OEPTH OF GROUT SEAL�'4 Cl 3.![ SPECIFICATION 1 R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY D f 1Ixt( _ GROUT BRAND NAME Of ' f AMONITORING GROAT SEAL PUMPED:.VYw ❑No CONCRETE PEDESTAL BY DRILLFR:❑Ya■ 0N4 jA S APPROX.DEPTH LOCKING CHESTER BOXfSTOVE PIPE S PROPOSED CONSTRUCTIONIDRIWNQ METHOD: MUD ROTARY A!ft ROTARY AUGER CABLE OTHER 1 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:"I CERTIFY THAT IN THE PERFORMANCE OF THE WOPK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING Oft 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 VST 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION&AT L209I 468$423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X Title_ �b s,l _ _ Date ILDT PLAN IDrsw to Swiel Scale._'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED I. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 5, 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. DEPARTMENT USE ONLY Appliostlon Accepted By Date Vi•2,3' Area Grout Irnaection By Date Pump Inspection By Dote Destruction Inspection ByDate ►/L�[�� /� .,/�� /� f Date Comments Y 1� E W■ L�, I l�V lr� ( /1 <., .........,.,..,_.,_ ACCOUNTINO ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PFAMITISERVICE REQUEST NUMBER INVOICE WI (0