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APPLICATION FOR WELLIPUMP PERMIT J SAN JOAOUIN COUNTY PUBLIC HEALTH SERVIGes ENVIRONMENTAL HEALTH DIVISION P 0 BOX 386,446 N.SAN JOAQUIN ST.,STOCKTON,CA 96201.388 (209)468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ) (Complus in Triplieatt) APPLICATION IS 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 DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APtdP�(2SOo 1. /J CITY Z&AI✓" PARCEL SIZE/APNi JW-2110-17 OWNER'SNAME IDSGO /[>��/[l�`P. l� ADDRESS 4l,� (/nriMa �h.,Z$[YI �Q k[l}Q PHONE&C7 �Y2•�-I<e�,.. ADDRESS ] � ✓/M/�L 5eA LIC/ PHONE -3J�^+ 9HSCl7lF}I�IEk /G+h?'c, Ul✓. �.Al��;hY �'^-�- ADDRESS_2J'ZCI&v", Jo_C uc►C'.'s-7 PHONN!9, - / TYPE OF WELIJPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL P ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL I J ❑New❑Repalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O TTYPE OF RUMP) //l ❑OUT-OF-SERVICE WELL ) ❑LGEOPHYSICAL WELL♦ 1 SOIL BORING DESTRUCTION:6a 2 4ZlYlt Cll[,11,-l- �i1 lt�'711I �lC 1 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION{ q ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D ❑PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION B ❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑MONrrORING GROUT SEAL PUMPED:❑Y- ❑No CONCRETE PEDESTAL BY DRILLER❑Yr 0N S APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTION/DRIWNQ METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER/ y[{►� yyC,�j IHEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'L CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUBCONTRACTING 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'$COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED IIIN�SPEEC'TTII`ON$A�T�(200)468.34423.COMPLETE DRAWING AT LOWER AREA PROVIDED. 510-d X /t TItI.�La-4 f. CACI.;�L+17/J("' I l`L�1�_!`Il'J D.t._�'��T,, Q!� PAT PLAN(Draw to Sol.)S..l. 'to 1.NAMES ISTREETS 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 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 Applicatlon Accepted BY lil ` 1 2/`�"rte"—✓' D.te ` Ata Grout Inspection By Dai. Pump Irop—l—By Dat. Dmt,mtion IropecHon Byy�_ (,,p�,,L_ 7�H/- / , p �/�-�Y�. �D—_.t-/�. Comments: I�'\ WI LT UT't�� Ii5 �G )I I n1-. 4— (/eN u► +q2 URS ACCOUNTING ONLY: AID/ FACR PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE PERMIT//SS-ERRVII�CE REQUEST NUMBER INVOICE