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APPLICATION FOR WELLIPUMP PERMIT * " AN JOAQUIN COUNTY PUBLIC HEALTH SERV, ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 (2091468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triprkata) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLICHEALTHSERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# I f,-�i' f/7 �L � CITY 1y r ! PARCEL SIZEJAPNN OWNER'S NAME CI (,�}' i'�]©n l �[_. _.{,I'i'i[.--i i ADDRESS ! I 'L `I7 3c��rJ" PHONE# 11 V. /�_y i ,e _ CONTRACTOR �'`Gi-,r' "G r'tnZ r L"-• ADDRESS IQ��5 A I^�Li✓-by-A-C--4 f LIC 'L F� PHG.E 15 -3.37-V31 SUB CONTRACTOR T ('i f i ri 1% '7'} I - LL ADDRESS 1 sZ 061 z-V3 I i4,y rus ucs(�7eZ� �,PHONE TYPE OF WELUPUMP: NEW WELL ❑ REPLACEMENT WELL X MONITORING WELL IF 1~ 3 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New 13Repair H.P. DEPTH PUMP SET Fr.. FIRST WATER LEVEL 19 (TYPE OF PUMP) ❑ OUT•OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING 8 ❑DESTRUCTION: INTENDED USE TYPE Of WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATIONS DIA.OF CONDUCTOR CASING}AAA" D ❑ DOMESTICIPRIVATE RGRAVEL PACKISIZE TYPE OF CASiNGISTEELfPVC r Y 1- DIA.OF WELL CASING�:2 !/)e D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH Of GROUT SEAL 1 I -Pe SPECIFICATION S . l/c / R 11IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY�_`(�,U, t V 001' GROUT BRAND NAME C�J Ktrit[ -,P e� E , 9MONITORING GROUT SEAL PUMPED: ❑Yee ;AN. CONCRETE PEDESTAL BY DRILLER:jWYac ON. $. y APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE S PROPOSED CONSTRUCTIONMRILLING METHOD: MUD ROTARY AIR ROTARY AUGER 4 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 PERSONS SUBJECT TO WORKMAN'&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 CALIFORNIA.- T CANT MUST CAU.24 HOURS I ADVANCE FOR REQUIRED INSPECTIONS AT(20014683423. COMPLETE DRAWING AATLOWER AREA PROVIDED. jAffifflailaw Signed X r�.� f TitleAIW ,��-y► sfy�lc/ D4te � PLOT PLAN[Drew to Scelal Scale 'to 1. 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 DIRECTTON. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS S WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ...... ..... ................ .... A.�l.tL�4�.(,�e.L. -� i t- i- -...-., .. - -. DEPARTMENT USE ONLY Application Accepted Bl'� - _. Data LS,,l.� Atea Grout Impaction By Date Pump Impaction By Data Daettuctlan Impaction By Date ` ) ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#1CASH 'RECEIVED BY DATE POWITISERVICE REQUEST NUMBER INVOICE i 3501 k 1