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APPLICATION FOR WELLIPUMP PERMIT N 0S_.�a,� l JOAQUIN COUNTY PUBLIC HEALTH SERVI, i'AYMit ENVIRONMENTAL HEALTH DIVISION IVT P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 RECL=jVLtD (209) 468.3420 AOR 0 5 11096 SAN.10,'.4LjIN (,�,t►NTY NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PUBLIC HFA j'� 9rE�V�C Ir (illi► S ENVIRONMENTAL ►4FA� j�y�(,��{�// CsIn 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 CN,1 la'+Cf�'�VRRISAN JOAQUIN COUNTY DEVELOPMENT TITTLE, CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. ENVIRONMENTAL HEALTH DIVISION.` JOB ADDRESSOR APNJ_ 2GyU 0. T.Aka-�• 0+ , . CRY PARCEL SIZE/APNJ OWNER'S NAME ADDRESS PHONE J CONTRACTOR �qt-1tlt:- �••-�lVt�`p`A.tAAjL•-��, Vvod'^AI�C.Wsa-.�-. 4''�G. ADDRESS 15�� L''I. �T.I C.QV"'1✓y4 m"• se�,Iv.a LJEJ PHONE J ` 1 1� l� SUB CONTRACTOR If W �J� 1\t'tig �'� �• • ADDRESSIS 1+ i 1 iq C./� �5��10 lU•Z �? U �^ + LIC' PHONE J I�`� -•Z V I TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL J ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL J ❑ New ❑ Repelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL J � SOIL BORING � g ❑ DESTRUCTION: (DR A v INTENDED USE TYPE OF WELL 1 CONSTRUCTION SPECIFICATIONS t a ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING D ❑ DOMESTIC/PPoVATE ❑ GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC T DIA. OF WELL CASINO p L_s ❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E {❑-y Ls� MONITORING GROUT SEAL PUMPED: ❑ Yea ❑ No ' Q �' CONCRETE PEDESTAL BY DRILLER: [1y. ❑Ne S APPROX. DEPTH LOCKING CHESTER BOXMTOVE RPE S PROPOSED CONSTRUCTION/DRIWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHERIAa'Aa 4k 1A4'- 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 16 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 16 ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' ANT MUST CALL j'°lS{i IN ADVANCE FOII ALL REOU111ED INSPECTIONS AT f2M1 Iis-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Bwned x _ �. Z�- 0�-- . `� . C. Title v. N�, Pfo..�; s_ f �fj�2/96 4 RA Dn. PLOT PLAN (Drew to Seale) 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 OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FY. STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ADolloatlon Accepted By Grout Inapeetlon By DEPARTMENT USE ONLY Date Pump Irrpeetlon By Data F Area �P/ Deeimctlon IrwoectkmBy Date m�J Coment.: ✓/�'� £ S� �/ ACCOUNTING ONLY: I AID# I FACS PE CODES I FEE INFO I AMOUNT REMITTED I CHECKs/CASH I RECEIVED BY DATE I / o /l3 1 �5 / 1 /&(---- Dna INVOICE