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APPLICATION FOR WELLIPUMP ll rm OUNTY �AN J ENVIRONMENTAL HEALTH DIVISION IRVI R E L C � o P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 9520138B 09T 1 Ai 1065 �,ai (209) 4883420 FNVIRGONTAL HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED RERMIT/SIRVIM (Complete in TFpliut@) t✓GCl APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIUICNN..(CO,UU�NTTY DEVELOPMENT/TITLE,CHAPTE(Rj9-1115.3 ANDTHE STANDARDS OF SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JO OB A DfiESS/OR APNX�0�O Vl PA LIC!C.� �C+F 1 LJ.�� CITY T!'I/ r PARCEL SIZEIAPNi I 1 / p row R, ene n� �iGYGO `•, OWNER'SNAME- 1111v h11 U \ nLOrO'✓ I ADDRESS a✓J OO o S Imo// pp�� I1 PHONE A`jS/OK� 3 Z CONTRACTOR W00?�W Or 1t1Yk1 ADDRESS Pv.gd 't b rV0U.3c%" PHON o 1-C. y390 l(Y' sue coNTRAcroRk orAU-fIA; J- ADORES -.vnl Stx��• S.,i'C�400u PHONY a.?-S TYPE OF WELLIPUMP: NEW WELL ElREPLACEMENT WELL YY MONITORING WELL I rnwlb ❑ OTHER INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL t ✓ ❑Naw❑Repair H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL 0 TYPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL♦ ❑ SOIL BORING B ❑DESTRUCTION: t INTENDED USE TYPE OF WM CONSTRUCTION 6PECIFiCATION6pp II A ❑ INDUSTRIAL L❑I OPEN BOTTOM .�/1.� DIA.OF WELL EXCAVATION_ny ,�1_'I l DIA OF CONDUCTOR CASING_ D ❑ DOMESTIC/PRIVATE 0 GRAVEL PACKISIZC' 1a TYPE OF CAGING/STEEUPVC PVL Se.�44AA1141G�(/".(, DIA.OF WELL CARING 2 D ❑ PUBUCRAUNICIPAL ❑DRIVEN TTTT DEPTH OF GROUT SEAL fir, SPECIFICATION T B ` ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLE�rtf bXy -f- i I GROUT BRAND NAME n+4.0 G Mca '00. . E i`� MONITORING / GROUT SEAL PUMPED: CRY- ❑No CONCRETE PEDESTAL BY DRILLER:❑Ys [IN. 5 n APPROX.DEPTN 6O r LOCKING CHESTER BOXISTOVE RPE �_��jlll• .1N IB�, s PROPOSED CONSTRUCTION/DFULUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW 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 WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECTTO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMR IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEHBATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL`M/ HOURS IN ADVANCE FOR ALL REQUIRED IN&MnON�S AT IM) COMPLETE COMPLETE DRAWING AT LOWER AREA PROVIDED. Bacrw l X ga'n" ��.�� /�1 71,1a ST-,"/ [oto U/ 4 let Data PLOT RAN IDraw tp Scale)Sub 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROMISED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH URECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTIINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. 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. .....,. .. .`. ..:... ....... . :. ... S. ..:.......... .. ....:... . i.... � pEPARTMENT USE ONLY Application Accepted BY Data G,..lmp ,pn BY T 'a Date /I Y1�6-�5Pumplrts atlon BY Date Daetructipn Impaction By Date COMM Commenta: m ( W 17 ACCOUNTING ONLY: AID0 FACY PE CODES FEE INFO AMOUNT REMITTED CHECKOICASH RE VED BY DATE PERMITISFRVICE REQUEST NUMBER 3SO /0// 2 - t