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APPLICATION FOR WELLIPUMP PERMIT F t�N JOAQUIN COUNTY PUBLIC HEALTH SERVI6 # ENVIRONMENTAL HEALTH DIVISION i P 0 BOX 398, ., STOCKTON, CA 96201-398 344 WfSEA e,-r, a (2091488-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED } (Complete in Triplicate) , I APPLICATION IS HERE BY MADE TO THE SAN 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/u�,AND'TTHE STANDARDS OF SAN JOAQUIN COU[N�TY1 PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ' JOB ADDRESSOR A�P}NXy'` `�`" 0 !1rT CITY�7 t\C5-T y��/-�J�� meq^ PARCEL SIZE/APNM OWNER'S NAME _5`1PON -�� a� ADDRESS ✓'Z' kit � S'` k\MtA PHO x599 -3o3:S- CONTRACTOR `�� MIL'I •p•AADDRREss{~}Ov15T�4,'ICA�}45 *{ �.[0(a�-H PHONE d1 Lo 1.5 SUB CONTRACTOR ADDRESS ° UC# PHONE TYPE OF WELLMUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ,9 ❑ OTHER .S i ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL Y ECEJ 13 Now 13 Repair H.P. DEPTH PUMP SET FT.,.fFIRST WATER LEVEL �.; -,,IIID (TYPE OF PUMP] ,. - - - - - +, " ❑ OUT-OF-SERVtCE WELL ❑ GEOPHYSICAL WELL X ❑ SOIL BORING 8. L -iAC45 S' ---n brJ RSM c-YJ AA--, *DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONB j1 A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION_ I O• DIA.OF CONDUCTOR CASING k 'D ❑ DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEELIPVC 5 E'L'I• 4�.Py�-• DIA.OF WELL CASIN/G� Lt 0 L4 ZI V ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL �' t I SPECIFICATION s W 4C) ,_ F ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME 01&%C --J-A10jT� E ❑ MONITORING GROUT SEAL PUMPED: ❑Yee [IN. CONCRETE PEDESTAL BY DRILLER:❑Yee ❑No S z. APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S1 PROPOSED CONBTRUCTIONlDWLLIN4 METHOD: MUD ROTARY, AIR ROTARY AUGER CABLE OTHER II � 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 WHIGS THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING 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 CAUFORNIA," T APPLICANT M C URB IN ADVANCE FOR ALL REQUIRED INSMCTIONS AT 12091 4683423. COMPLETE DRAWING AT LOWER AREA VIDED. E clI $1rNAt� OF V4v4 bR%LII r/-� R � q/� 1 Signed X TtAM Title `� vl 7Date �P i -rim J. c-Dc*jA,-() " r t PLAT PLAN{Drew to Scale)Scala "to t 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. ij EXPANSION OF SEWAGE DISPOSAL SYSTEMS: ' 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 1I LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. If ON THE PROPERTY OR ADJOINING PROPERTY. �roL.. Z- r Z R a. E I .... I � �'ts' 11— h , c. sJGSM voL c r 0� h - Zz .... ... .. o, ... ............ . + 3 ++ 3 3 Y r c}� JAL 3 j4, -.... ... :...4 x 4 . . tilij - x i. ............ .. ..... ......... .... -. ca L �s-,o L7�S1 (�. 4 .. r -=DEPARTMENT L�ONLv - fApplication Accepted By L Date - Arae Grout Inspection By Date Pump Inspection By Date i1 Destruction I tion y Date ) 46 Commenb: � � Sr s f I ACCOUNTING ONLY: AID#' FACX PE CODES FEE INFO AMOUNT REMITTED CHECK#�ICASFI RECEIVED BY DATE I PERMITISERVICE REQUEST NUMBER INVOICE _ �G