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APPLICATION FOR WELLIPUMP PER, SAN JOAQUIN COUNTY PUBLIC HEALTH SLnvICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SA JOAQUIN COUNTY DEVELOPMENTT TITLE,CHAPTER 9-1115.3 AND TH STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, / r JOB ADDRESS/ORIA1IPAANI 7O I0 I ` gIv i CITY�(!,,CSI l / PARCEL SIZE/APN# �i lI L - V OWNER'S NAME Al nn C/�A LI�I(�i L cLI)��l �I A'cr" 5 A�ADDRESS ) y J�Or S. 94/ K r T"PAM PHONE,1010 092-/ 7 D CONTRACTOR SYL- -T1C\jM �y ��(' Un ADDRESS'2366 W(°om Dr UCI {� S�z26b PHONE I SUB CONTRACTOR ADDRESS LICI PHONE I TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER�iC'7A�� 5 ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I 1;2( ❑Fle,uelr H.P. DEPTH PUMP SET FT. C (TYPE OF PUMP) FIRST WATER LEVEL ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING R ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION �" in" DIA.OF CONDUCTOR CASING D ❑ DOMESTIClPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEVPVC C DIA.OF WELL CASINO ?I r Q 11 PUBUC/MUNICIPAL DRIVEN DEPTH OF GROUT SEAL �_n ' SPECIFICATION l7 o R ❑ IRRIGATION/AG 11G OTHER GROUT SEAL INSTALLED BY SP LLLI`U GROUT BRAND NAME MONITORIN ��A 0. �L5> GROUT SEAL PUMPED:JMYes ❑No CONCRETE PEDESTAL BY DRILLER:❑Yw ❑No S APPROX.DEPTH '�7!5 LOCKING CHESTER BOXA' �FPE 5 PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE9EBY 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 ANC 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 WHICV THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUS-CONTRACTING SIGNATURE CERTIREE THE FOLLOWING• I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'!COMPENSATION LAWS Of CALIFORNIA.' E APPUC NT M SST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED 1 PECTIONS AT(200)460-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. slaved x / o/L lM ntlb_ G1 .1 Date 1-2y-00 PLOT PLAN (Dr to Scale)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 DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OVTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED S. 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. rL>r?0s��9 P lezo Neer Luc.*t1Uus DEPARTMENT USE ONLY Appllcetlon Accepted By '(\�""' Date ��/I Area t' Grout Irnpeotlon By Dete Pump Inspectlon By Date Destruction Inspectlon By - / Date Comments: V � _- ACCOUNTING ONLY: AID# FACT PE CODES FEE INFO AMOUNT REMITTED CHE 941CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 2(Z Z