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APPLICATION FOR WELLIPUMP PERA,,.,, SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH 01VIS10N P,O, BOX 388, 3U4 EAST WEBER AVENUE, STOCKTON, CA VSMI-M {2091 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete M TTlpliestel APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AN131OR INSTALL THE WOW DESCRIBED.TITIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTFR 9-1115.3 AND THE ySTA�JNDARRDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNI_'T! 3 4 I /l QR r/1/111 G-11W)g4p I r {�CttY 1`19 0 ` PARCEL SIZEIAPHI— 3 A G 1'.rS {{ OWNER'S NAME T ! k& L. Y.//I1 r `�flR, T-RR { TARDA_l ADDRESS 6 q A10e ri{ 01 WAY{f- OW PHONE f 20Y- f 31p`/LG/)O $6AQ-CONTRACTOR I/r<J U N �x SS C I"1 F_S.S I7 R1UC-.#-5 A�D�ES9 L/ FUt SEI C 1 I-Yl C lq ICJA-7–ZQS�1 Z 7 PHONE! IZ7l�� M SOS Al.�.11lr'f V j." StA I r-E E• I)O10J, c A Y s«o �T/� S-9 BwcoNTRACTORLEEUV14RQcaAltuLr�iuA- o � ADDRESS UCERIr S? O� PHONEr�rb 61 —v� TYPE OF WEUJPUMP, ❑ NEW WELL El REPLACEMENT WELL 1:3 MONITORING WELL$ ❑ OTHER .�. ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL E J ❑New❑Repetr H.P, DEPTH PUMP SET FT. FIRST WATER LEVEL (TYPE OF PUMP) t7 ❑ OUT-Of-SERVICE WELL ❑ OEOPHYSICAL WELL R SOIL BORINGS L?OR/NJ6'S 7-0 30 11qq ` 8 TantsTRUct1ON: 13/kXF141- W1rN CE,sTF/yT-.a wTy,vi-r _ Si, I $�+21N� TJ Sot INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION* A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASING D ❑ DOMESTICIPIUVATE ❑GRAVEL PACK1817f TYPE OF CASINGISTEEUPVC DIA.Of WELL CASINO D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECtfICATION /T ❑ IRRIOATIONIAO ©OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E © MONTIORINO OROUT REAL PUMPED: 11 YOM 11 Me CONCRETE PEDESTAL BY DRILLER:Ely. ❑Ne S APPROX.DEPTH LOCKING CHESTER BOXMTOVE PIPE 5 PROPOSED CONSTRUCIIONIOWLIJNG 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 JOAOUM 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 WOW FOR WHtCI THIS PERMIT IS ISSUED,I BNALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HITTING OR SUR-CONTRACTING SIGNATURE CERTIFIEI THE FOLLOWINGS 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS DI CALIFORNIA," THE APPLICCANNTTT MUST CALL 24 HOURS INS jADVANCE FOR ALL REQUIRED(INSPECTION*AT 12r0�01 400-3427. COMPLETE DRAWING AT LOWER AREA PROVIDED. BIOn9d X, //✓Ik./"lh-ter f OI- {/i!V rl.e.K Title IQC41IS rE/z G^f� �'�C110(l�l�� D+te //-1 7— yr _ �E�wf4eo caneskt. Af✓,�S PLOT PLAN I0r9w to 80-191 Scale 'to 1. NAMES Of STREETS OR ROADS NEAREST TO On BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SFWAGE 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,tNCLUDINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. SEE A IT Ac t-+15A IL DEPARTMENT USE ONLY i APPlloetlon Accepted BY D+taAre+ Gout IMpeollon BY Date Kemp frnpection By Dote Dedtactien InepectIon By Dole CemmOx+t+: ACCOUNTING ONLY: AID$ FACIE PE CODES FEE INFO AMOUNT REMITTEDCHECK$f ASH RECEIVED BY DATE PERMITISETIVICE REQUEST NUWISER INVOICE