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N w APPLICATION FOR WELUPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 95202 (209)468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete M TripRellte) APPLICATION 13 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 PUB/LIC H4 EALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORESS/OR APN* �� !� A UIS t A-�( CITY /ti14+V k/*d c4 - PARCEL SIZE/APN* «,&,)"Z OWNER'S NAME QL l' ��O /—be-47CA 7Ai C. ADDRESS r" ^`-.1,CA �/S_'7--J60-T PHONE ��LSJ^�S� . =b Ko I/cav/ V1!� f CONTRACTOR C�,ag ll)��.gA�CC C�GLS tet�'G-. y :/UC. ADDRESS A!'r/FS.+F✓7C�1—LICf PHONE F'7Xf^q14 S39] �!/,,,y ADDRESS w,�a.- e2.C� ggss-?UCff.4g�s+tfL PHONE-71 Sf3c� SUB CONTRACTOR t^-r�t�'Q -- TYPE OF WELL/PUMP; NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL* OTHER9 INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL* J ❑New❑Rapek H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (I YPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL* ❑ BOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL - CONSTRUCTION SPECIFICATIONS /N A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION S_4. � DIA.OF CONDUCTOR CASINO D PW ❑ DOMESTIC/ VATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC pVC iY' DIA.OF WELL CASING 3 ! D ❑ PUSUC/MUWIPAL ❑DRIVEN DEPTH OF GROUT SEAL r? / SPECIFICATION R ❑ IRRIGATION/AO -(XOTHER G 't'ZSP "� GROUT SEAL INSTALLED BY GROUT BRAND NAME �yt kl k- E fia MONITORING-R�� 't GROUT SEAL PUMPED:9)Yes ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yes ❑Ne S APPROX.DEPTH Zg 4-o 3F I LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER I HMS 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 JOAOl1tN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,1 914ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT tN TItE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- THE PPUCANT MUST CALL 24 HOURS 1 VANCE FOR ALL REQUIRED INSPECTIONS AT(201 400442!. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X Title ,e /mowce.-A e_'LvLV;S jw S'85F 2- Date AT PLAN Mrew to Sods)Seats 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING 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. 2. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RAINS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. .. S4< � �!A ,rf��rc-h . a DEPARTMENT USE ONLY 1� Application Accepted By / Date r C/ RL— Ase Grout Impeetlen By 1 w..nr�-'1 Data. Pump Inspection By Date Desbtretlen Impaction By � Date CemmeMs• E 10 om- q Ci A-4= — I ACCOUNTING ONLY: ND* FAC* PE CODES FEE INFO AMOUNT REMITTED CHECKIMASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 36 Z l