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Y APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 000 I53 ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201"388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 5 YEAR FROM DATE ISSUED r� (Complete in Triplicate) iJ r2� 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 �y5(iTITLE, CHAPTER 9-111 5.3 AND THE STANDARDS OFF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. % y JOB ADDRESS/OR APN# / �q L) i N r.J -+ 7-A IE ( CITY -S,L U I" / o PARCEL SIZE/APNN OWNER'S NAME CA / it'• r: T / I:CH QlC tj U•"J ADDRESS C iJ•1' CSA PHONEN 209 / �� i ] J/ 21 :i U A t:, CONTRACTOR 6jE6C-cnue L�✓:V'sy1 L.. al e&.L.;C IfCn% ADDRESS A,, - .I. t, `.✓a.—,L,6.Iu Li LIC# PHONE #9/y "�.l Z• `�lla) SUBCONTRACTOR iJt-y W'rN Sff,41h`t L.1L /lW "l: h�� Lwl:a/EKY ADDRESS ssIfIY}PHONE# 7#4 TYPE OF WELLJPUMP: ElNEW WELL ❑ REPLACEMENT WELL ® MONITORING WELL #[ M W # I f." � ❑ OTHER 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 ❑ INSTALLATION El WELL SYSTEM REPAIR ❑ CROSS -CONNECT REP IR"I / ❑ VAPOR EXTRACTION WELL # RECEIVED BY I DATE Sigrro,X l- - -� Tftle Qpt-rations Managlar Date 3-16-95 ❑ New ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL U (TYPE OF PUMP) �\ ❑ OUT -OF -SERVICE WELL ❑ GEOPHYSICAL WELL # ❑ SOIL BORING g ❑ DESTRUCTION: /l� A INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION � ZI%L h DIA. OF CONDUCTOR CASING IV R D ❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC 4-1..A, j7 y C' DIA. OF WELL CASING - j#I C.yL D ❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL L* - .7 -5 SPECIFICATION R 1jy1� IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED 13Y h/----1 : %Ex GROUT BRAND NAME E ILX MONITORING GROUT SEAL PUMPED: Id Ya LI No CONCRETE PEDESTAL BY DRILLER: K Yea [IN. S _ APPROX. DEPTH [ '1. Ir C��L LOCKING CHESTER BOX/STOVE PIPE 1 Zr fti �'r.i; LI�%uC.,t C{y��I� S PROPOSED CONSTRUCTION/DRI LUNO METHOD: MUD ROTARY AIR ROTARY AUGER_ _ CABLE OTHER O 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 V FAC# 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 PE CODES FEE INFO CALIFORNIA.' APPUCANr i CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091468-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. CHECK#/CASH RECEIVED BY I DATE Sigrro,X l- - -� Tftle Qpt-rations Managlar Date 3-16-95 350 ( n� 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. Application Accepted Grout Inspection Destruction Inspection DEPARTMENT USE ONLY Date [ • ✓ 5-5 Aree�; 5(5 1 Date Pump Inspection Date ACCOUNTING ONLY: AID# V FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY I DATE EST NUMBER INVOICE 350 L-.