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;CtglIV x0'18°1995 Date Area 6F,/ Date DEPARTMENT USE ONLY Application Accepted By Grout Inspection By Date Pump Inspection By APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIutS 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 E (Complete in Triplicate) NVIRONMENTAL HEALTH APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APP1ICA4i44IT4iilrkaMAIF,NCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE, CHAPTER 9-1 1 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# 01.'1 t,1i4 k i CITY -34C442--ktr OWNER'S NAMEA c‘qcvc, PARCEL SIZE/APN# ADDRESS 223, IA)•, t•tt.tottc) Drive, ()it( is-61PHONE 2 0 i• :14 Cs%Zii(l;, CONTRACTOR CI E.11.1-111A;CAer GiArC' 41 C I.1 25 j(4-1-kihiC 6[)11#41)( 0.2 ) 5t1ILIC# PHONE #610 153.7 SUB CONTRACTOR 0,1 9 50 ADDRESS a VIntZ ,tA 91553 Lic# 01- PHONE # 31C ••-i ,Z1 • arril ) /1 _ TYPE OF WELLJPUMP: 0 NEW WELL 0 REPLACEMENT WELL LI MONITORING WELL # .... . OTHER , -_ _______ lig INSTALLATION 0 WELL SYSTEM REPAIR . 0 CROSS-CONNECT REPAIR IAPOR EXTRACTION WEeL # -, 0 New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) 0 OUT-OF-SERVICE WELL 0 GEOPHYSICAL WELL # ,_ °OIL BORING - i 8 0 DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A 0 INDUSTRIAL 0 OPEN BOTTOM DIA. OF WELL EXCAVATION DIA. OF CONDUCTOR CASING D 0 DOMESTIC/PRIVATE 0 GRAVEL PACK/SIZE TYPE OF CASING/STEE DIA. OF WELL CASINC -.6 i rs 0 PUBLIC/MUNICIPAL 0 DRIVEN DEPTH OF GROUT SEAL 1 SPECIFICATION' ' ' , -- 0 IRRIGATION/AG 0 OTHER GROUT SEAL INSTALLED BYStell-4-04Le IT M,3 GROUT BRAND NAME E 0 MONITORING ,, GROUT SEAL PUMPED: rir Yes 0 No anti,. CONCRETE PEDESTAL BY DRILLER: 0 Yam S APPROX. DEPTH I:1 4!LOCKING PU CHESTER BOX/STOVE PIPE S AUGER .., ... CABLE PROPOSED CONSTRUCTION/DRILUa3 METHOD: MUD ROTARY AIR ROTARY OTHER 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 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." THE AP ANT MUST CALL 24 HOURS IN ADVANCE FOR AU. REQUIRED INSPECTIONS AT 120914119-3423, COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed XC --‘ek Ct‘f."6 ger YtA Title GNIrtant-A0 AM) eteanatier Cutyrik " 9S PL T PLAN (Draw to Scale; Scale " to 20 NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED OUTLINE OF THE PROPERTY, GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 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. Destruction Inspection By Comments: - Date o/ _ ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED B DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 0 ( P7 /756 P/05- . _ / .. 5,8 - C 6-R POP 7/ / S'