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I APPLICATION FOR WELLIPUMP PERMIT •SAN JOAQUIN COUNTY PUBLIC HEALTH SER& ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988, 904 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in TripIksta) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT r ER Pill AND jlNE S►ANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH(SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNI_' '"L lll+.'C�Yv//'\ 'lrrsd CITY_ (-T 7;4 20 PARCEL SI2E/APNJ A YrG�'pa r� OWNER'S NAME L%rC-l�Y'V �'L j�+ f`Cl�'7'L ADDRESS S rtvY��"`G d2.n Y l .�i y LP4k—, w� ONE,r e) 2-4S 71 CONTRACTOR T� "(i'Z✓ �r11%u11C. �^ Vl r�C IL35� MOA''-cz- Pm-,(N - IL-B>"i '"Z H DDRE66 12AA3CN6((JLZ ,4I CRL1 LIC* SPHONE* GJG+1U I SUB CONTRACTOR ADDRESS LIC/ PHONE TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL* �DTHER ±MPGR MCMI ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL* (TYPE OF PUMP 11Nen❑Racal, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL* ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION EPECIPCATIONG TI A ❑ INDUSTRIAL VOKN DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ OOMESTIC/PRIVATE SIZE TYPE OF CASINO/STEELP C DIA.OF WELL CASING D ❑ PIBUCMUNICIPAL DEPTH OF GROUT SEAL SPECIFICATION R A❑ IRRIGATION/AG GROUT SEAL INSTALLED BY GROUT BRAND NAME E 9 MONITORING � GROUT SEAL PIMPED: Ely. No CONCRETE PEDESTAL BV DRILLER:Ely. ❑Ne 5 APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONSTRUCTION/)ELUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL 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 WOW FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I TH IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WOgKMAN'e COMPlNe ON lAW8 OF CALIFORNIA.- TH • C NT ET CALL 341OW5IN ADVANCE FOq ALL gEGUIHm INiP[CTIONB AT 1]OEI MBJI2l. COMPLETE DRAWING AT LOWER AMA PROVIDED. 91pnsdX im. QI�2 rLC-T�/�� Dna PLOT PUN (Draw to SeNe)Soale 'to O 1. NAMES OF 61REETS OR ROADS 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 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 !.. _. ...... ....._. > C .y + C ......... ._... .... ..J. '.... ...... .... ... '. ._ V I a .. .. J :. ... ..... 3 a DEPARTMENT USE ONLY �Q Application Accepted By �I Date U 1. (6 Ary Grout Impaction By Date PVmp Inapacti.n BY Data DettrpeUon Inspection BY Data Commanb: -}-� ^ 8 1 ACCOUNTING ONLY: AID* FACT 4 ' PE CODES FEE INFO AMOUNT REMITTED CHECK*/CASH RECEIVED BY DATE! FBIMIT/SERVICE REQUEST NUMBER INVOICEES 9 9 b to