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APPLICATION FOR WELLIPUMP PERMIT 3AN JOAOUIN COUNTY PUBLIC HEALTH SERO- r ENVIRONMENTAL HEALTH DIVISION �O �'� P 0 BOX 388, 446 N. SAN JOAOUIN ST., STOCKTON, CA 96201.388 (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 SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# / l O J TYi U S % /Z E C r' CITY 5-r0 C- r5 % O til PARCEL SIZE/APN# y &,te- OWNER'S NAME CFl QE�T. of lkA.us AOAT-AT1a�: 4r57,QicT/OADDRESS PO. (lox 2o48 SCOL h,,3 (Q PHONE#209. 948.%8}3 // 3'435 S010PIs4E gl_v4. '� , CONTRACTOR 6E000Q EinlJr r2.0U A.. EN 74c. 60/.1S u /SR.VTS ADDRESS c;I,_I-_ 4i-.4.VC GA LIC# PHONE # 916. ,S2' 9/l e I\\ 'mss �4 L U SUB CONTRACTOR J'f a..i A I L[,i.J ADDRESS / 5 t5 I's0.� // W VST LIC# + PHONE # ��• 3�i' 2415 , oisrA. ca 9 fs r 7— TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL # O'oq - M W I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # J ❑ New ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL '.f.J /-G.�-} 0 (TYPE OF PUMP) ❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL # ❑ SOIL BORING B ElDESTRUCTION: ` ft INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 11INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION I O �iJcN DIA. OF CONDUCTOR CASING /U A 0 0 DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC 4 P ✓ C DIA. OF WELL CASING 4- TA 1�1 0 ❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL .Z t 'lU SS l SPECIFICATION S CL, t d i Lt 41) P J G R ❑ IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E 4W MONITORING GROUT SEAL PUMPED: "Yea [IN. CONCRETE PEDESTAL BY DRILLER: MYm ❑No S APPROX. DEPTH }S - p O O Fu.t LOCKING CHESTER BOX/STOVE PIPE I? II _lR Af Fl c. 600eR S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY —A -0t— FAUGERX X CABLE OTHER I HE9EBY 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: " 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." E AP IUCAN UST ALL 24 ISO URS IN ADVANCE FOR ALL REQUIRED INS(�CTIONS AT 12091468-3423. COMPLETE DRAWING AT LOWER AREA PROVI ED. Signed X ,% 'b/yf', l , ��.l'L /4� 7 Q Title L� ` � Date PLOT PLAN (Draw 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 OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. 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. ....:......:...............:................... :....... ....... ;.................... ..,.......:.............. ..... ......... :...... .. .. .. .............. .. .. .. .. .. .. ............... ................... _...:;......�.._..;..... _:...... b ......:......;....., .. .. .. .. .. .. .... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ' i .. :. .. .. .. .. .. ......... .. .. .. .. .............. .. .. .. .............. .. .. .. .. .. .. ..;...........................:...........................;..... ..:..... !... ..:.. .. ............. ...... ....... ....... ................... .............. ...................... ............... ....... ........... .............. ............... .............. ..... ................ ....... ....... ....... .... .. .. ............. .............. ....... ......... ............................... ............... . ............ .............. .............. DEPARTMENT USE ONLY Application Accepted By Data v I,j(. 3 Arm I ACCOUNTING ONLY: ( AID# FAC# r 1, 'PECODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE EST NUMBER INVOICE 13 0 5 1 D