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APPLICATION FOR WELLIPUMP PERMIT USAN JOAQUIN COUNTY PUBLIC HEALTH SERV?w9 ENVIRONMENTAL HEALTH DIVISION P 0 BOX 308, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICDmpwt6 in Triplintll JOAQUIN COUNTY APPLICATION IS NTY DEVELELOPMENT TITLE,HERE MADE TO THE SAN JOAQUIN COUNTY FOR q PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN CHAPTER 9.1115.3 AN/D;THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR ApN! 1153 Vanaer &.l711+ rlei CITY/,t Y)[C el.i //^�• r y r1 /•W 1� /�E I l0 I U I/.Y{ YJf /i Y CdLJ �. A PARCEL SIZE/APN# OWNER'S NAM CONTRACTOR ADORESPHONE ! p2 -2-73 6 ADDRESS �gq/ SUBCONTRACTOR LICC -02( SUB ADDRESS IJC! PHONEf TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ja MONITORING WELL! ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTMCTION WELL f ,/ ❑N.❑R.p.ir H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL (TYPE OF PUMP O 11OUT�OF-SERVICE WELL 11GEOPHYSICAL WELL# ❑ SOIL BORING S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ /ngyp A INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION PJ DIA.OF CONDUCTOR CASING W O ❑ DOMESTIC/PRIVATE AGRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC TVG DIA.OF WELL CASING Z" D ❑ PIBLIC/MUNILIPAL ❑DRIVEN DEPTH OF GROUT SEAL ISI SPECIFICATION 0.02 SemeluIe, R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY S es GROUT BRAND NAME P0rrldlyl Cer Z-P' E 'MONITORING / GROUT SEAL PUMPED:NY. [IN. CONCRETE PEDESTAL BY DRILLER:❑Y. ON. S APP OX.DEPTN_--qo LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTION/DICWNO METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER I HE9EBY 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 WOW(FOR WHICH 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 PERRO)WANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.-',r1a APPOCANLMUST CALL M ^LMB IN ADVANCE FOR ALL REQUIRED IIINNNSPPE�CrTIIOONS AT IZ2O/8H1,/4�88�3 n. COMPLETE DRAWING AT LOWER AREA PROVIDED.c.. vgO X� /y !///•'✓t.c / Title ;Q/ JGL/ /V'P/ 4 101 Dlts 3 �/ ROT PLAN IDrew to S .I Sub 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING 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 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUC S PATIOS DRIvpw�xt.,�Al MB ----2LjULaQfffaXM kDJOINING PROPERTY. IA .O LD EXPLANATION A ` / u I � / / / / 9 "PROXIMATE LOCATION OF MONITORING WELL ' B PROPOSED MONITORING WELL IMATION SITE PLAN y'�ir c.m.naH . mt 1 1153 VANDERBII.T TF1ENT USE Y �'`�I� �f� /�MyAT�T'LECA. CAWFBR!AY D.-„F e, rN APPIIUNon AweptaM BY�(y4 F.S V1 \ L � w�'��TCI , Y Date Grout Im;,wIon By Det. Pump Ir portion By Det. Dmruction Im wtlon By Dee Commanw 2 ACCOUNTING ONLY: AID! FAC# -J , PE CODES FEE INFO AMOUNT REMITIN TED CHEC"ACASN RECEIVED BY DATE PER oUT/SERVICE REQUEST NUMBER VOICE -oo MIN is ZIS7