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" APPLICATION FOR'WELLIPUMP PERMIT (.wSAN'JOAOUIN COUNTY PUBLIC HEALTH SERLA ENVIRONMENTAL HEALTH DIVISION i P,O. BOX 988. 304 EAST WEBER'AVENUE, STOCKTON, CA 95201-388 { t (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 4 YEAR FROM DATE ISSUED ICompleta iln TripIkatel APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THISAPPLICATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER S-1 116.3 AND THE STANDARDS OF SAN JQ QUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, j JOB AODRE88IOR API/ CITY S fTIG/C fY7I—_ _PARCEL SIZEIAPNI OWNER'S NAMES ADDRESS Q ONE Z�6 CONTRACTOR ADDRESS 1 LIC+ PHONE h9lxbw 4m 'I fA SUB CONTRACTOR .�. ADDRESS S � „�PHONE# �� 1 t TYM OF INEUMMPi 13 NEW WELLS 13 REPLACEMENT WELL �.�-NIONR'fORINO WELL IP �!L ❑ OTHER s ❑ INSTALLATION 0 WELL SYSTEM REPAIR l ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL s J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O TTYPE OF PUMP) f ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL It ❑ SOIL BORING 8 yCTDEBTRUCTION I{ I INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A { ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMESTICIMVATE ❑GRAVEL PACK/SIZE • TYPE OF CASINGISTEEL/PVC - DIA.OF WELL CASINO D ,I { ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R i ❑ IPMOATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E 011 e ❑ MONITORING > %N GROUT SEAL PUMPED. ❑Yea ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Y. CIN. S f APPROX.DEPTH i LOCKING CHESTER BOXISTOVE PIPE S k ' PROPOSED CONSTRIICTIONIDAILLING METHOD; MUD ROTARY AIR ROTARY AUGER CABLE OTHER I� J I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:9 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH , THIS PERMIT IS ISSUED,I 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 CALIFORNI E NT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INNSSPEC�T.IIOONNS !8, 2! S AT 12081 44 . COMPLETE DRAWING AT LO AREA PROVIDED. / Signed X Jpt_� Title C` • •`•'��S OC.!.4, �5�--�.A1 D!'� Date PLOT PLAN,Draw to Beale/"le "to 1. NAMES OF STREET$OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE OMPOSAL 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 ,I B. 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. j I E p :....: ., .. ., ..., ... .,.. ..,.. .. .. .. .. . .. .. . I I : : 1. : I -� I ...... .... t. .. .,. ... .. ., -. - ., .. :....,, ..:................,. .,..,.,.,..,., ...... .,..,.......,.. .. .: ........ .. .. .. .. .. - - aY 11 I �E II DEPARTMENT USE ONLY Application Accepted By Date •� Atee__-Le' Grout Inspection By 4 Date Pump Inspection BY Date Destruction Impaction By Date , f � Cemmenta: II ii ACCOUNTING ONLY; AID# FAC# I PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED a DATE PERNITISERVICE REQUEST NUMBER INVOICE I 3�✓06a 0 9-a-16 01 5 Ih