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APPLICATION FOR WELLIPUMP PERMIT .61 JOAQUIN COUNTY PUBLIC HEALTH SERVIL ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 (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 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# IN9/ Wes f _Di,i, i-Ail I/ 7 're r ,, t y. it2o1 , CITY ---/ -ra e i PARCEL SIZE/APN# OWNER'S NAME S-i---e_ k 14— ...._(...4.... I ADDRESS 7— '/'-/y /• AA Lk rilft#4,-/ Te-v-ry 4---)#.1,1pHoNE # CONTRACTOR C.- 'le 1&xIA:4_.:1- e Y.- 6) (-clip —Tod . ADDRESS h 25" 4• 1-4,4thr Arc— .4-14.104-e 44..... PHONE #'3/01313 /734 1 SUB CONTRACTORAI'fC ileit DV 'I 1 (1 VI Eh V e r-oki m C. A e valis-.... ADDRESS.' .8-)( -. -d.2.3/ P... a.#-Ic A (.3 uc# (7...7-44 .,' 7 PHONE iCht7:357: ,L),3 ,b/ t-e rreVel/A— YPE OF WELL/PUMP: 0 NEW WELL 0 REPLACEMENT WELL 0 MONITORING WELL # El INSTALLATION 0 WELL SYSTEM REPAIR 0 CROSS-CONNECT REPAIR Pr OTHER 15 p ti.4- etc 0 VAPOR EXTRACTION (,)ELL # J 1:1 New 0 Repair H.P.DEPTH PUMP SET FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) 0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL # 0 SOIL BORING 8 0 DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION -( DIA. OF CONDUCTOR CASING D DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE ). 02,0 TYPE OF CASING/STEEUPVC WC DIA. OF WELL CASING D......Z. .. PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL i V SPECIFICATION R....Z.. IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BY 1/..^1'- GROUT BRAND NAME j21 MONITORING GROUT SEAL PUMPED: 0 Yes ,No CONCRETE PEDESTAL BY DRILLER: 'Ye. 0 No S..,,, . e APPROX DEPTH -, LOCKING___TEliti 13.17STOVE PIPE S PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY _ AIR ROTARY AUGER _ ". CABLE OTHER -7---.: ' 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: 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHIC THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIE THE FOLL ING: * 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 0 ....-..1 CALIFORNI ." THE CAN US 24 HOURS IN ADVANCE FOR ALL, REQUIR PECTIONS A4 12051 468-3423. COMPLETE DRAWING AT LOWER AREA PROVI D. ....,, Title \ ' 0 r Date 7 -7-j '''----- - P t PLOT PLAN (Draw to Seale) Scale to NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED STRUCTURES, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ON THE PROPERTY OR ADJOINING PROPERTY. DEPARTMENT USE ONLY Date '3 .31 .7 5 Area 352,49 Application Accepted Grout Inspection By Destruction Inspection By Comments: Date q ci 5 Pump Inspection By Date Date ACCOUNTING ONLY: AID* FAC# PE CODES FEE INFO AMOUNT REMITTED CHECIUNCASH RECEIVED BY DATE REQUEST NUMBER INVOICE I 1 Cc (PL1 5 330 ‘PEFtMIT/SERVICE ....-,—.....--..-S-'"'