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iI APPLICATION FOR WEL (PUMP PERM"') SAN JOAQUIN COUNTY PUBLIC HEALTH S",CES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WESER AVE 41JE, STOCKTON. CA VM1'88 (2091468-34 20 ; NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED jl ICompNt2 In Tr Iir,Iltrl APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOBADDRESSIOR APNsJZ1 D - J� � � .,,,•,,,, „ I� c 2{pDr.I PARCEL SIII 459-`332—a4 OWNER'S NAME Lltq W ,(��,onu �� ADDRESS G Q"""f'HHONE,r[�t� g CONTRACTOR J�gLULCF- 61/ ADDRESS urlb L1cN PHONE Zb9 x(32 y �• 8534 0 SUB CONTRACTOR IF ADDRESS LICO PHONE I V TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL �� ❑ MONITORING LL I © OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR a ❑ CROSS-CON CT REPAIR ❑ VAPOR EXTRACTION WELLS J ❑New❑Repw, H.P. �, DEPTH PUMP SET FT. FIRST WATER LEVEL CI (TYPE OF PUMP) ❑ OUT-0F-SERVICE WELLI ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B LCI DESTRUI1LI re- f —AA 1 Y1 f / l�t� ,+ w INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICAn N A IJ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINOISTEELIPVC DIA.OF WELL CASINO D I ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R 11IRRIGATIONIAG 13 OTHER GI'OUT SEAL INSTALLED BY GROUT BRAND NAME ❑ MONITORING GROUT SEAL PUMPED: ❑Yap ❑No CONCRETE PEDESTAL SY DRILLER:❑Yr ❑Ne 3 APPROX.DEPTH I LOCKING CHESTER BOXISTOVE PIPE 3 PROPOSED CONSTRUCTIONIDIOLLING METHOD: MUD ROTARY ¢ AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT 1 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 CERrIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PER6MT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAIVS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY HAT IN THP PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT If ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' MUST A 24 NO IN ADVANCE FOR ALL REQUIRED INSPEE�CCTION5 T 12041/4!8-0422. COMPLETE DRAWING AT LOWER AREA PROVIDED. p/ Slened X Title �C.L I Date fa PLOT PLAN IDrew''to,Sulo)II 'to 1, NAMES OF STREETS OR ROADS NEAREST TO OR O'wOWG THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTN)N. 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 Fr.- STRUCTURES, T:STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. . .. -. - i :....- -.,... .-..: 1 r ....., i L DEPARTMENT USE ONLY i Application Aomwted BY Dete__.i 1 14 1�jArea Grant impaction By Date 'yr Pump Inapeetio i By Date - Oeetruetion Impaction Sy Comments: S i IYj ACCOVNTING ONLY: AIDA S FACT ii PE CODES FEE INFO OLINT REMITTED CHEEC�KOMASH RECEIVED BY DATE PERMITJSP.RVIC EQUEST NUMBER INVOICE ,