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APPLICATION FOR WELL(PUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICfe ENVIRONMENTAL HEALTH DIVISION P O BOX 388, 445 N. SAN JOAOUIN ST, STOCKTON, CA 55201-328 (209) 468.3420 LEON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED &Complus in hipli"t61 APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 15 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THEE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AODRESSIOR/rAAPJNi �.�� `'� 1 `�-t CITY Pucq ICVA _ PARCEL SIZVAPN* OWNER'S NAME/ 1 kA Wt ADDRESS��I� r/ �. �L ON • CONTRACTOR }• 1 n �fI l Fl✓' AgDRE55 f/�1� 1 � NEI SUBCONTRACTOR �+ AA O CI ADORESS23 r+� 1 4IF`iLVn U� )ter d"7 TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER oN ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL aI _ J ❑Now❑Repoi, H.P. DEPTH PUMP SEi FT. FIRST WATER 0 ITYPE OF PVMPI EY OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I jj y^ �j'�////y�4(trJp�SyO�y'L RIDING �,L,. DESTRUCT.Inu. - 1�I'v C"�'1 VY;•V3 �h>�E(�(fOW.J INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEFUPVC DIA.OF WELL CASING D ❑ PUSLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED 8Y GROU r BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yr ❑No CONCRETE PEDESTAL BY DRILLFR:❑Ym []No S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE S PROPOSED CON,TRUCTIONAMLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER b 1 HEREBY 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 15 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN',CGMPEN,ATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTAACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 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 C HOLP&IN ADVANCE FOR ALL REQUIRED�INSPECTION&AT 12091408-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X Title T'yl'�`� f P Y Irl.l)ej Q11 Data t' PLO N(Draw to Scale)Scale 'to 1. NAMES 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 PROPOSEO 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. •f darnCllAY TMIMNAY —��-" I a1M--3 t ,r1 1 i� 0 %J S1AMM .. AS11.1 1111CRI 1111 .. YW-4Q COMPETE % 0 1 �r rrl-4Q G� . .. r. 0r, ron11Ee PIMP MAO tMAllpll GFNLRALIZI:IJ SHL PIAN l-C1;I=ND: FI<IIOLM PROPERTY a MUNITONING WELL 1702 JACKSON STRLFT FSCALON, CALIFORNIA O VAPOR LXTRACTION WELL PRMARtp rot MRS. MARGRET CKHOLM p AIT-1— xAEs _ SMTH lur[ F.:1 M'/eEV/SR111 h Te a to rEEI 1/AIE:_ 1-a-N. T-RiLIT{r z tRA"K.IrsNel. DEPARTMENT USE ONLY Appllostlon Accepted BYt4ja�Y P L,� ��" ... Dote • Araa Grout Inspection By Data Pump inspection By Data Destruction Inspection By Date Comments: ACCOUNTING ONLY: AID# FAC* PE CODES FEE INFO AMOUNT REMITTED CHECK#!CASH RECEIVED BY DATE PEAMITISERVICE REQUEST NUMBER INVOICE 3 0`�- 16-,�-b