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APPLICATION FOR WELLIPUMP PERMIT -a- SAN SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (209) 468.3420 NONREFUNDABLE PERMIT EXPIRES 1 YERR FROM DATE ISSUED IComp19U in Tripl-w9m1 APPLICATION IS HERE By MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS pIYLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE S`T'ANDARDS`OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. Q(- W•LSo Se AA 5-Elrte.�- CITY � PARCEL SIZE/APN# JOB ADDRESSOR APN# �r.a aI { a /1 c OWNER'S NAME IT`r GLr CAtCk �NI L\'�1Qh� ADDRESS 3-Z-1 `+I�SS1�� t+�\VCi —PHONEN`7�� S/TI 'GZLI Eh1J, ro� -�t*al lGl-I'L- torp. ADDRESS IZ�D0 �T✓QP�\E's UCX ci6L PHONE/7•'�9 S�'Z'ZZI CONTRACTOR SNIT SUB CONTRACTOfl:5bt EiYJtM + ADDRESS 23('5 � 01 5yjCi % �\r, LIC#51 AA PHONE# p '16'0 I L TYPE OF WELL/PUMP: ❑ NEW WELL !_ ❑ REPLACEMENT WELL MONITORING WELLN �❑y OTHER INSTALLATION [I WELL WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR VAPOR EXTRACTION WELL# -3 J ❑New❑Repair H.P. DEPTH PUMP SET-FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) ❑ OUT-0F-SERVICE WELL 13 GEOPHYSICAL WELL# ❑ 601E BORING R ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 16`,/ DIA.OF CONDUCTOR CASING y D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC V C DIA.OF WELL CASING Ti�y 1_ `_ D ❑ PUSLIC/MUNICIPAL 1❑yDRIVEN DEPTH OF GROUT SEAL 10' SPECIFICATION W,ellt]N:i'V R ❑ IRRIGATION/AG Lr OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME O/'li3O,W0- rVQ.'j•-'�rf OMONITORING GROUT SEAL PUMPED: ❑Y. [IN. CONCRETE PEDESTAL BY DRILLFR:❑Yea PrNo S APPROX.DEPTH /O LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONETRUCTIOWDftlWNG METHOD: MUD ROTARY AIR ROTARY AUGER L11" CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND 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 WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES 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 OF CALIFORNIA.' THE APPLICANT MWT CALL HOURS/I1N ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120914083/442,3,. COMPLETE DRAWING AT LOWER AREA PROVIDED.2 signed%��I. /Yt/v�.L� LL�C/Y 1 Title 222; (/V LQ,U\-(' Data Jo 3" ' N(Dr.to se.la)s.la�_"to 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. DEPARTMENT USE ONLY �L^I Application Aooepted BY Date tC�(/ Ar. Grout Impeotion By Date PUMP ImPeotlon By Data D.truetion lmpeeHon By '/ DatO Commend• MdAffd y t �- 4 Ita Do✓ ACCOUNTING ONLY: r AID# FAC# PE CODES FEE INFO 4P.AOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE ,o a.