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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAOUIN ST., STOCKTON, CA 95201.388 (2091 4683420 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 WRIT SAN JOAQUIN COUNTY DEVELOPMENT TRUE. CHAPTER 9--111 1 S.3 AND THE STANDARDS OF SAN JOAQUIN COUNIFY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISIONT. JOB ADDRESS/OR APN. J- 'J w- F'�N 1 (N rh f� CITY I IIU C / ( ( �7 _ PARCEL 312F/APN! WOO Y 1�1� OWNER'S NAME 1 1 l I 30 /'d Q (/� ADDRESS 365- F— F F0y1 T (.y /_ {F C �./y� / � rY! PHONE! y3)5 - 131 6 CONTRACTOR_()?ClciIc'd /I tkdli Jti^NIL-Z5 ADDRESS 1703 V -1.4 -cc I -H., 5�1lA ucF PHONE I`Ij6 f%�(1 `l SUBCONTRACTOR- SOI S ��'l(/�C�4 �i Qy1 SCNVI (�JtS C ->7a [// ADDRESS3441 507`l9 �P. IJ PN Ilia UCI r 6yL> PHONE dwYY>-1371 TYPE OF WELIJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 1 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 1W J Nmv ❑ RepNr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 RVP OF PUMP) U ❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL / ® SOIL HOPING I S C3 DESTRUCTION- INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS[[ ❑ A DIA. OF WELL EXCAVATION INDUSTRIAL ❑ OPEN BOTTOM O /R� DIA. OF CONDUCTOR CASING — O ❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASINGISTEEUPVC DIA. OF WELL CASINO ❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL l U SPECIFICATION ♦ 1 N ❑ IRRIG11ATION/AG OT/IER GROUT SEAL INSTALLED BV GROUT BRAND NAME IOP 1 IQ 4 LeM,tt 1 AP E� O G . GROUT SEAL PVMP D: ❑ Y— 3Ne CONCRETE PEDESTAL BV DRILLER: ❑ Y.. CIN. S APPROX. X.. DEPTH_ 1 O 1 [ �C ITLOCKING CHESTER BOX/STOVE PPE S PROPOSED CONSTRUCTION/GEOLUNO METHOD: MUD ROTARY AIR ROTARY AUGER_ CABLE OTHER 1 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 All BEGULAT IONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED. I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: - I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF C ALIFORN1A..- THE APPLICANT MUST CALL 2. HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120.1 400,3.23. COMPLETE DRAWING AT LOWER AREA PROVIDED. slon.n X 14 x,Till. b zo (- 051"i T D.t. Z - ;z .7 -4 y - POT PAN I.— to SoN•I SeN. ' 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. J. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNOnEO FIFTY FTIt . STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING POPERRY, GRANT LINE ROAD I_ u<� e R I srnl I ua'-T9 \ I uw_z I I R.rr EXPLANATION 9 APPRONIIf.TE LOCATION OF NOI'ITOPINO 1rus • PR OPOSF.D RORINC!IIl'DROPIIN[H LOCATION a__' _-.. e Ie I RDAN RFAI. ESTATE. 2. DFPAITTIENL.UEE NLY_�� A F' ROAD RLI APPIic.tlon AcceoteE B 7' ( 2NIA — -- •--ih! — \��,..Z Groot lnA—lon By D.ta Ptnno InApoetien Br D --ti— Imo.otloe D.1. ACCOUNTING ONLY: A100 1AC1 PE CODES FEE INFO AMOUNT REMITTED /CASH RECEIVE. BY DATE PTtMIT/ ERVICE REGUEST NUMB INVOICE