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� f APPLICATION FOR WELLIPUMP PERMIT .;AN JOAQUIN COUNTY PUBLIC HEALTH SERV. ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95MI388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 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 16 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND TH STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# �0 901 �,(�` JIvC CITY_�rcc,-1 `+� PARCEL SIZE/APN# -Ito 6� A Y R p 1 6 A � �I^3S 0,501 ,s. 1144 fW.� P) A +1U q OWNER'S NAME Illn� �(1A(„t�trl�i[' el�LtJ�f(` ^�t,�e�(�l 5 �� •ADDRESS__ 4A rel//�l' /PHONE/;d?)792 CONTRACTOR SQL-�-T„VM �kp 10rc, 1 " ADDRESS �tahC.fr1 Or LIC# �i�2269 PHONE# 265 %H7iZ- SUB CONTRACTOR ADDRESS UC# PHONE# TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER jif7AIIIQ7r 5 ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS t A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION �"AD DIA.OF CONDUCTOR CASING /(/ D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC 21,x'7 DIA.OF WELL CASING Iru D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEALG3 T r SPECIFICATION 5 1 R ❑ IRRIGATION/AG ❑OTHER\ GROUT SEAL INSTALLED BY_ 5 P LLVfZV A GROUT BRAND NAME -U CkT rw4t f MONFTORING(�{ //`(1GL LL,Sl-\ GROUT SEAL PUMPED:j2Yea [IN. CONCRETE PEDESTAL BY DRILLER:C1Yes Ii No 5 APPROX.DEPTH J/ -��T/// LOCKING CHESTER BOX/ OOPE S PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER 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'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING• '1 CERT" THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN-S COMPENSATION LAWS OF CALIFORNIA.' E APPUC NT M ST CALL 24 HOURS IN ADVANCE FOR ALL REQUIREDTIPECTIONS AT 1209)448-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. 6loned X F2x71 ( Tit�ls �j%�i Gfo(Uc-rsT- Date /-2y o 0 �� File v X Ahv PLOT PLAN (Draw to Scale!Seals '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 OUTLINES 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. t-goSt. P IezG W4er- CU 1�vs Q DEPARTMENT USE ONLY Application Accepted 13Y Data �'ryI Aras Grout Inspectlon By Date Pump Inspection By Date Destrt>ction Inspection By pp / Date Comments: • T-J r4` 214 � f awl Y- t ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHE941CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE 7 Z