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APPLICATION FOR WELLIPUMP PERMIT SAN JOADUIN COUNTY PUBLIC HEALTH SER ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA'95201588 (209) 4663420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED J� [Complete In Trlprmtil APPLICATION IS HERE By MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.,13 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/09 AMS A,vEeJ '�A < A."D V,U•.I ( �l k4e&69) CnRY PARCEL SIZE/AIT# OWNER'S NAME V1UJJ I ADDRESS 1 •6•8uy 556 1 P P.ELwE �w/ Iw 4w,a.V PHONE CONTRACTOR TCKIJION �JM1mpy..rV* '++C• ADDRES647 Lour )E 11CI �3(3$I RHONE I` ef8G 9875 SUB CONTRACTOR ADDRESS LIC# PHONE TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑ N.❑Reo.1, N.P. DEPTH PUMP SFT_FT. FIRST WATER LEVEL O TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# 1 1 SOIL SORINmg Ln—c+ >�5 B 11 DESTRUCTION: / O INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OhWRtrM9AWrgBR 2.6'f oD DIA.OF CONDUCTOR CASING NA D ❑ DOMESTIC/PUVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGMTEELIPVC NA DIA.OFWELLCASING .UM ❑ MBUCWUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL .SJ//Lcc SPECIFICATION 1- a, ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY 52,1 SYo wl GROUT BRAND NAME E. 11MONITORING GROUT SEAL PUMPED: ❑Y. ❑No CONCRETE PEDESTAL BY DRILLER:❑Y. No •(Iw`I APPROX.DEPTH LOCKING CHESTER BOXMTOVE PPE MA \% PROPOSED CONSTRUCTION/DIOLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER V /P"/✓E.STrAWLL V``- I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK HALL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WOIK FOR WH THIS PERMIT 16 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN't COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CEMIFI% THE FOLLOWING: -I CERTIFY THAT IN E PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 19 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION UWBq CALIFORNIA.'_ THE Ai PUCANT MU&T HOURS IN ADVANCE POR ALL REQUIRED INSMTIONS AT 1�2011114&94M22. COMPLETE DRAWING AT LOWER AREA PROVIDED, p SIOn.EX Tllle_ 4fG L�OT�oG tS1' Dm ROT PUN ID,.w 1.6 .1 S 4 'Ro 1. NAMES OF NT ETS ROADS NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSE 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENSIONED OUTUNFS 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. 1 Appilc. QEPMTMENT USE ONLY / Z/, 0on Aeeeplad BY All. G'..IMA«tlOn BY D.m PvmP IMP«tlen BY Oae Oavucllen Imo«&len BY Dae Demme l.: Ia T� Coy 2Dte/ c on — �T � �' 9S 02-0 ACCOUNTING ONLY: AID# FAC# PE CODEJI FEE INFO AMOUNT REMITTED CHECKMASH FI CH BY DAT PSSMITISERVICE REGUEST NUMBER INVOICE -� X800