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_ I APPLICATION FOR WELLIPUMP PERMI'�A SAN JOAQUIN COUNTY PUBLIC HEALTH SEM.�ES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388,304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468.3420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICGmplth in TT1pBetml APPLICATION 19 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 TRIS\,�CH�APL EER 15.3 AND `A1�ND[t`ME STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION.,A JOB ADDRESSMF PNI 1(A V Vt Y\ w(ti�1" 6�wlw Q CITY \1�l\C.`'G ^ //+I(� I PARCEL 82E/APNI �I��\�W a2 OWNER'S NAME��,�1r � 11,1 �I1/,n'4(1,}��n�h\ t�.I ADDRESS n`C11C��' TUJ` ku)hvl /�G PRONu-EI CONTRACTOR VYY\ILS VkA/'>� t"t``1%sm ADDRESS�O�JLP�3FILO VIS UCI PHONEI0 �v ` q �j ADDRESS '�Z2 LIC# RHONE I SUB CONTRACTOR TYPE OF WELLMUMP: JO.NEW WELL ❑ REPLACEMENT WELL 161 MONITORING WELL I,��,3 r ❑ OTHER �' ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑New❑Rep-11 H.P. DEPTH PIMP SET---FT. FIRST WATER LEVEL O RVFE OF PIMP [3OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL I ...,. ❑ SOIL BORING - B ❑DEeTRUCTON:' _ A INTENDED USE , TYPE OF WELL CONSTRUCTION SPECIFICATIONS ^� I ❑ INDUSTRIAL .1 1,0 �OPEN BOTTOM DIA.OF WELL EXCAVATION L5 � SG! DIA.OF CO UL CAST CONDUCTOR CASING 1�C^ D ❑ DOMESTIC/PVATE I$GRAVEL PACK/SIZE 35 TYPE OF CASING/STEEL/PVC � F C— DIA.OF WELL CAGING ZYI O N ❑ PUBUCRAUNICIPAL ❑DRVEN DEPTH OF GROUT SEAL ` 31 SPECIFICATION A �❑R IRRIOATION/AG ❑OTHER GROUT SEAL INSTALLED BY V�1-�� 1hJ GROUT BRAND NAME E 1Ly MONITORING - I 1 GROUT SEAL PIMPED: ®Ys ❑No CONCRE IEE PEDESTAL SY DRILLER:❑Vee ❑No S APPROX.DEPTH S hS LOCKING CHESTER BOX/6TOVE RPE C\ F,U1—\N S PROPOSED CONSTRUCTIONANEWN METHOD: MUD ROTARY AIR ROTARY AUGER_ CABLE OTHER I HERESY CERTIFY THAT I HAVE MPARED THIS APPLICATION AND THAT THE WOW WUL BE DONE IN ACCORDANCE WITH BAN 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 WOR(FOR WHICH I J THIS PERMIT 18 ISSUED,I SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN't COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: I CERTIFY TH/ IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN-6 COMPENSATION LAWS OF CALIFORNIA.- THE C NT IB CA HOURS IN ADVANCE FOR ALL REQUIRED INSPEC[TONS AT IM)4SSJ42f. COMPLETE DRAWING AT LOWER AREA PROVIDED. SynepX I Title ZCn �1� -D.t.•8'Zz,-9(� (I iL MOT PLAN (D'.ry to Scale)We 'to 1. NAMES O RTREETS 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 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. l j 1 � a ^/ ^��( DEPARTMENT USE ONLY Application Accepted BY q 1 Y t\la-Ll� 1 6L��! Data Grout Inspeptlen ByData Pump Inepee8on By Dna DmUuatlen Inspection BY Data 1 Commeote. I ACCOUNTING ONLY: AIDI FAC# PE COD" FEE INFO A44OMT REMITTED CHECK#ICA RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE