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APPLICATION FOR WELLIPUMP PERMIT a SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Ok-P �S Y ENVIRONMENTAL HEALTH DIVISION 304 EAST WEBER AVENUE, STOCKTON, CA 9M14r (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APPLICATION 13 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANWOR INSTALL THE WOW DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN#�5, �i S, 1-). � (ZZ—)S-�UII \}'ICIT� I�r(1�,iL,Q••� PARCEL SIZE/APNI 6 QCJ^e OWNER•B NAME W e"� e,(,1 Fair M 'Sop i I c r11 I d l _ ADDRE88_�Pr,}L '`� PS qo,CA �015 PHONE R 20911+3 a-b 1 s3/ � � �l I�1m 1 U I Ic Pwe- .+w CONTRACTOR`.]C•C]S,,.. �t C7AC 11(-1 L'vyl l� ADORES CA,Aw} . 36 lie uc, AM PHONE 0_51CLmc-"--, � . S? {�O W_4?,-A.BUB CONTRACTORADDRESS / PHONEIt SC3)" cs TYPE OFWELL/PUMP!'xNr*wee",5•v ❑ REPLACEMENT WELL MONITORING WELL I I W OTHER �Q_<S Wel I L -( ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑ RVPE OF PUMP) Now 11Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p ❑ DVT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ BOIL BORING g ❑DESTRUCTION: INT DED USE TYPE OF ❑INDUSTRIAL �❑-y OPEN BOOM DIA.OF WELLEXCAVATICONTION. 'p/x_!8 - i 11,1 DIA.OF CONDUCTOR CASING &A p ❑ DOMESTIC/PRIVATE VJ GRAVEL PACK/BRE AFL 1 IID TYPE OF CASINO/STEEL/PVC LLaaSS�•r IA OF WELL CASINO ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL � ( F4PECIFICATION ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY"r✓IeIOROUf i1'1E, BRAND NAME r E )I MONITORING 5 GROUT SEAL PUMPED: 0 Yea [IN. CONCRETE PEDESTAL BY DRILLER:MY. [IN. S APPROX.DEPTH - pp to LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONIDRILLINO METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER I HEREBY CERTIFY THAT 1 I4AVE PREPARED THIS APPUCATION 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:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'@ HIRING OR BUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: �l'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- T PPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSKCTIONS AT[2001408-3423. COMPLETE DRAWING AT LOWER AREA PRO IDED. Signed X Title S!- �"'� `R i. � Data I �� C' PLOT PLAN IOraw to Sealel Beale 1;1. '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,GIVINO DIMENSIONS AND NORTH DIRECTION. 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 FT. STRUCTURES,INCLUOINO COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. mw 14 '0 CQ Sl DEPARTMENT UBE ONLY Application Accepted BY_ O�� - /�—?I_Ar Data M Grout I �JImpaction By � �+/cp Date � /a/ pump Impaction By - bealnretlen Impeclion By Data Date Cemmenta:_ 01pa- m WS ACCOUNTING ONLY: AID# FAC/ PE CODES FE INFO AMOUNT REMITTED CHECK#/CAB" RECOVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE Pub.Heafth Serv.-Enviro.173(3/96)