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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERI 1 ENVIRONMENTAL HEALTH DIVISIOAk P.O. BOX 388, 304 EAST WEBER AVENIR_, STOCKTON, CA X201388 12091 488.3420 NON-REFUDOAILE PERMIT EXPIRES I YEAR FROM DATE ISSUED , ICMRPIea M TtW kInt81 APPLICATION 18 HERE BY MADE TO THE BAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF BAN JOAGUIN COUNTYPUBLICHEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. L,. 9l JOB AODREt18,/yO/R APNF �// ' > r'.s,i - , ' i �, ' /1 1 i� cm .5 %� �. K i o /Y PARCEL BRE/APR/ : OWNER'S NAME , ADDRESS jJ/OS� �.�i'F. Z fl Vr PHONEI /Ji� ' � SJ4 CONTRACTOR � F �'LV� j>r . -'c) Ci`I(.'. �i''cIY H ?J ( ADDRESS lfd. r''d /VAr6c YT 6V */� UCF e"> Y .1Z PHONE # BUB CONTRACTOR /'�.D.'r4"N(G C� �l'�� E �`/G'. i=C`• i/l� U.r%•'f / ADDRESS < 1+24;Z41041Alir LIC# PHONE 1'7/�l �11- .75I TYPE OF WEUIPIUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL It ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL # . J ❑ New ❑ Repair N,P. DEPTH RUMP 8ET_FT. FIRST WATER LEVEL 6 nITYPE OF PUMPI ❑ OUT-0F-SERVICE WELL - ❑ GEOPHYSICAL WELL # 3(J SOIL SORING B PDESTRUCTION: ILNTENDED WE TYPE OF WELL CONSTRUCTION SPECIFICATIONS q > I3 1p INDUSTRIAL ❑ OPEN BOTTOM DIA, OF WELL EXCAVATION )�G DIA. OF CONDUCTOR CASINO D �o � DOMESTIC/PRIVATE 11GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC N//3} I DIA. OF WELL CASING /11/ D �❑ PUBUC/MUNICIPAL 13 DRIVEN DEPTH OF GFOUT SEAL �c i� f L>&—, `� SPECIFICATION N I✓f' R `] IRRIGATIONIAO ❑ OTHER GROUT SEAL INSTALLED BY tGROUT BRAND NAME R%Lr-J' XQ ( '' r E EGA// N Y J(�7+I MONITORING GROUT SEAL PUMPED: ❑ Yee" CONCRETE PEDESTAL BY DRILLER: ❑ Vee t1ONe S AFRICK, DEPTH. 1lor LOCKING CHESTER BOX/STOVE RPE N/ S PROPOSED CONSTRUCTIONIDPWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHERf�2FOA2LUlt 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNFY ORDINANCE8, STATE LAWS, AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR 6111B-0ONTRACTING SIGNATURE CEPRIFIES THE FOLLOWING: - 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOURED INGMTHONS AT 1208! 488JM28. COMPLETE DRAWING AT LOWER AREA PROVIDED. Si#rodX �'� yy>� . EV�- Title Sin FF 6c4 /o $ 01i Dote PLOT PLAN (Drew to ScoteU SEMS ' to 1 , NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE BEWAGE DISPOSAL SYSTEM OR PROPOSED 2, OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMB, 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 PKIPERTY, DEPARTMENT USE ONLY Application MorelliBY One ` — � ` "� Arae— Groin lnepmtlon BY Dote Rene Iruo.ctlan IIY Date Daotrue8en Inepactlen BY Dote ACCOUNTING ONLY: AID# FACE PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 350 73 71 97T?�6 DSO