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APPLICATION FOR WELLIPUMP PERMIT SAN JOADUIN COUNTY PUBLIC HEALTH SER—ES ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,904 EAST WEBER AVENUE,STOCKTON,CA 95201388 1209)468.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION IS 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 SAI JOAQUIN COUNTY DEVELOPMENT TITTLE,CHAPTER 9-1115.3 AND THE/STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. � JOB ADDRESSIOR AP/N/ 101 tl, S CI n �J/og U 1 h ST CITY/1 ;J4,0d ot, ! PARCEL SIZE/APNI 150 X 150'/yy�l O ER'S NAME tt/-.T61 eY-41 SOV iW-. rTQ t'h Ih IJ�}�N'1-IO� ADDRESS_ l50 661( n 6Ak- ke,5f• ,CJ-17} PHONE*q15 Si2328`; CONI CTOR Md,-6-11 V-11; - ADDRESSP•o.(30)(22'31 kr"'d-C 10"LICir&OT2lo 1'T PHONE.gf685Zq$sf 6U8 CONTRACT TPh�yy ADDRESS LIC/ PHONE TYPE OF WELL/PUMP. ❑NEW WELL ❑REPLACEMENT WELL pl MONITORING WELL# MW I ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL/ J ❑New❑Rep•Ir H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL [ (TYPE OF PUMP) - ❑ J 11OUT-OF•SEflVICE WELL GEOPHYSICAL WELL Jr ❑ SOIL BORING � B DESTRUCTION: 0w4(,Zll wel w' Ilollous -mg.u1ws io '50-61C41— 5o,�hr�w/ n.eti-F Ca.�fe vii 1+'e-1, INTENDED UfE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION Z DIA.OF CONDUCTOR CASING O ❑DOMESTICIMUVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC '^DVG I, DIA.OF WELL CASING 0 ❑PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL I,-to So� ,G S SPECIFICATION R ❑IPELIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY 0/1 It/:L' GROUT BRAND NAME E ❑MONITORING GROUT SEAL PUMPED:V Yr [IN. CONCRETE PEDESTAL BY DRILLER:❑Y- ❑Ne S APPROX.DEPTH SOS LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONIDRIL11N0 METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER I 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 ANI 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 WHICI THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIEI THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS O' CALIFORNIA.- TH�Ey/�IPPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120S14aSJ42S.COMPLETE DRAWING AT LOWER AREA PROVIDED. Slanad-X /A�11/Y-lel Tltl* P-Oitov De. ROT PLAN(Dr—to Se1•1 S"I• I Itl 'tp 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 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. SSE *�i� 466 PZoz p�Au -1d f) of�c� 9tNS,TkwjMok) f)GT4( . _-.. I, DEPARTMENT USE ONLY �/f 2 Applicatlan Accepted BY D.I. // -2—�-� / Arr Grout Inpeetlon BY Date Pump Inpaetlon BY D•t• Dw—tlen I-P-tf BD.e• C. —w 'mment•: h °a�(oeo D33� �o Izr,n�L/�gc ll�Spc�rLo CQ4Sr t1No Wo^ttLYl1 dCi�l pnwrbslar}d ACCOUNTINQ ONLY: AIDI FACE PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED aY DATE PEIIMITIZERVICE REQUEST NUMBER INVOICE' 3►'�a2 (QD X5053DI -7-(o 1