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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION III P 0 BOX 388, 445 N. SAN JOAQUIN ST, STOCKTON, CA 95201-386 � (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSUED _. (Complete in Triplicate) APPLICATION ISN HERE E MAGE TD THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MAGE IN COMPLIANCE WITH SAN e11, k JOAQUIN COUNTY pEVLO2PMENT TITLE,CHAPTER'S--111 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMSION. JOB ADDRESSOR APNs 3 2 O S�c 1�Torli ST- t--� R1�� ,� `! - k yADDRESS CITY / PARCEL SIZEIAPNNN# - + OWNER'SNAME 1 I1V-- Nc. '320 S-r6c<-Mtj Sr Ii EN'PHON5qq- -�-035 [ CONTRACTOR \J-1--W DR t LL1 t--A GC7,B, s I R 10 v I STA (A appREss r 94$71 U"(oS$}S( IONo} SUB CONTRACTOR ADDRESS ; /[ LICs PHONE s TYPE OF WELLtMMP: ❑ NEW WELL ❑ REPLACEMENT WELL ,MONITORING WELL:f +" II ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR❑ !� ❑ VAPOR EXTRACTION WELL• J New❑Rapelr H.P. DEPTH PUMP SET FT. ITYPE OF PUMPF O FIRST WATER LEVEL - _ ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL N ❑ SOIL BORING g �A ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A` A A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION Or-ZS DIA.OF CONDUCTOR CASI G E�1 /�' D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC_5C J4 � DIA.OF WELL CASING � f ' ,o rl O ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL O�"`l 1 II SPECIFICATION-^- H .40 �ty--• R � ❑ IRRIGATIONtAG $OTHER GROUT SEAL INSTALLED BY J+- 1� GROUT BRAND NAME N 47'T��sF t' E ar ' ``MONrrORING GROUT SEAL PUMPED:XY ©No �f CONCRETE PEDESTAL BY DRILLER:❑Ya ❑Ne S p APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S ,� PROPOSED CONSTRUCTION/DRIWNO METHOD: MUD ROTARY AIR ROTARY - AUGERT�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,I SHALL NOT EMPLOY NS UBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT THE PE RMA CE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,I SHALL(EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THE C NT MUS C 24 URS ADVANCE FOR ALL REQUIRED INSPECTIONS T 71488J42a. COMPLETE DRAWING AT LOWER AREA Pfd ED. ori $ I�Ia1� air v tw +L w�, a�o� Data2 qS� BllOnad Title T I M J: tAC DO t� PLOT PLAN(Oraw to Sine)Scale "to !IWFT fie,- a I. 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 5. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. _ STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. II ON THE PROPERTY OR ADJOINING PROPERTY. ' ,'..... .._,...... _ _ s.... .... ........ ... .-_ - 4 - - I�.: j 7 07 v' . Act L ��.. . . . 1 ..............;.... . . : RA�RpAia fZ.ti.Uf-[T-o>= 1n�A�. .....:.. .....:. . ......;. `. . ....... .. .... ...... ..Y..: IVT//��1)11fal1lJ�1p{1f/�] DEPARTMENT USE ONLY Application Accepted BY r tr• �7^+�' r Date r L rM1 Area I Grout knapeciloj By Data — PUTP IrnPactlon BY Wap Date 4 - Destruction krupection By � �"Deter f Comments' " !� If ACCOUNTING ONLY: Alps FACS !! 711 e_� PE CODES FEE INFO AMOUNT REMITTED CHECKIfCASH RECEIVED BY DAT _PERMITISERVICE REQUEST NUMBER INVOICE F Il LW li ya -. P