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� APPLICATION FOR WELLIPUMP PERMIT AN JOAl2UIN COUNTY PUBLIC HEALTH SERI ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9520188 (209) 466.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Trlplkete) APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIMBION. JOB ADDRESSOR APN# o4 s-- r¢ I Gr — c) I CITY PARCEL SIZE/APNO OWNER'S NAME` bA:e r L-C/N i II/''J' ADDRESS / ) j/C � PHONER CONTRACTOR �1UJ//�'oNs/7 E'W��(L�jVjl '�.'� .% �" �, �.�] ''^^LL ,�". �? ADDRESS �n "lip' L;.l PHO EI •j�'/\.�-C�j SUB CONTRACTORMJ IZMF1L VA''-/cJ IV4V rN1/li-'!d'U1Fv,E</1�%J 'L ADORE 4/CNC/JC N 3 �ZTw'/� PHONE* I`ll TYPE OF WELLIPUMP: 11NEW WELL ❑ REPLACEMENT WELL IcnMONITORING WELL/ [3OTHER El INSTALLATION ❑ WELL SYSTEM REPAIR ,❑`CROSS-CONNECT REPAIR ❑ VAPOR Ex TRACTION WELL l j (TYPE OF PUMPI 13 N.11 Rr4eb H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL0 � 11OUT-OF-SERVICEWELL ❑ GEOPHYSICAL WELL IIL BORING 9 g ❑DESTRUCTION: �r�r'' I INTENDED USETYPE OF WELL CONSTRUCTION SPECIFICATIONS U INDUSTRIAL OPEN BOTTOM DIA.OF WELL EXCAVATION q t/�j /N- PIA.OF CONDUCTOR CA61N0��-LL 131:1IV/✓- ' p ❑ DOMESTIC/PRIVATE RAVEL PACK/SIZE TYPE OF CASINGMTEELIPVC P V[, DIA.OF WELL CASING L /N - D ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROW SEAL SPECIFICATION R ❑)RWGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E /M•-`L`AONITORING j GROUT SEAL PUMPED: ❑Y. [IN. CONCRETE PEDESTAL BY DRILLER:❑Y. ON. S APPROX.DEPTH 'S LOCKING CHESTER BOX/STOVE PIPE - g PROPOSED CONSTRUCTIONIMMUNG METHOD MUD ROTARY AIR ROTARY AUGER_CABLE OTHER / 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCE STATE lAWB,AN VIES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE E THE WO FOR WHICH THIS PERMIT 18 ISSUED,I SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERfQRMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFO TH APPL1C T7MC 11116 IN DANCE FOR ALL REGMRED IN57NS AT IS 14110 COMPLETE DRAWINGATLOWER AREA PiOVI ED. Blcn.ex TRIS / /'^�.j', GT F"'LC71�$/ 2s D.I.Dna PLOT PIAN IDI.tp S.IeI Sole 'to 1. NAMES O STREEtS OR ROADS NEA O 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 OUTUNE.S AND LOCATION OF ALL EXISTING AND PROPOSEO S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY 09 ADJOINING PROPERTY. DEPARTMENT UBE ONLY Application Accavtwl By Date R Arae 1 Orvvt ImP.tlon BY Dne Pvmv InePoctlon BY Dna O.tr.tlon Sap.ti�Lcnn��BY ,ry1p /j ,,,,� Io,1 1y 1y`I /� y� j, �I y�I�, Dn1e�K/�\Ar Comm.u:�V�l ryd q. raA 4d � I �I 'NNS W Il..t'V�.1 ©9 IAWI L✓ y, �f"1 V" V V I V ACCOUNTING ONLY: AID# FACF PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE Z�� IN 9-15o 4.5•�� 135h5