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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388,445 N.SAN JOAQUIN ST.,STOCKTON,CA 95201.388 (209)468-3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Tripliwal 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 COMPUANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COQNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORESS/OR APNIPock ,Eyqt ByP4R A OQI( SL/F10hroi 5G�{'raM�rvSTOCK 10N PARCEL SIZE/APNO OWNER'S NAME ,, C_i f\J Of/ �`04l)O(j ADDRESS ? 1 PHONE/ CONTRACTOR 4 JV&4(-(CJVp0 �n PIY'ONNt°Ltq' ADDRESS I�Q/ w.hd hCA L,%:'/f p, UCI PIONE/q.96-026 SUB CONTRACTOR ADORFSS LIC♦ PHONE' TYPE OF WELUPUMP: ❑NFW WELL ❑REPLACEMFNT WILL ❑MONITORING WELL' ❑OTHER 1� ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL' ❑Now❑R—I, N.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) pp11 ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL• uy 801E BORING (,P•O/)rO Q B ❑DESTRUCTION: (� INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A YY _ 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION I DIA.OF CONDUCTOR CASING O ❑DOMESTICtPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEVPVC DIA.OF WELL CASING D \ ` ❑PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 31 T-07't Py/ti SPECIFICATION / p ❑IRMOATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAMES/Lyy If A q �o/It��l'111L T E ❑MONITORING GROUT SFAL PIMPED:❑Vr [IN. CONCRETE PEDESTAL By DRILLFR:❑Yr QJ No 5 APPROX.DEPTH 3 , LOCKING CHESTER BOX/STOVE PPE 5 PROPOSED CONSIRUCTION/dOLUNG METHOD:MUD ROTARY AIR ROTARY AUGER CABLE OTHER I A'Ct FLU k 1 HEREBY CERTIFY THAT 1 HAVE PREPARFD THIS APPJCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN 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 WOW FOR WHICH THIS PERMIT IB ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPIENSATION LAWS OF CALIFORNIA.'' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS )AT./(2001460J423.COMPLETE DRAWING AT LOWER AREA PROVIDED.Q Blpned X�(jM/-V� //�L.(/'WVW\ Tlele Sa/HI•r 5lof LJOOL-S�I S 1 D.le L—( ` - PLOT PLAN 0—Io So—)Se.l. 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 NORTIH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S.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. S l��q Gil d DEPARTMENT USE ONLY 7 APPIIe.Son A-ooteA By 0-1- 0...t .I-OrmA I—P-11on BY D., Pump In.Pe,—BY DHs Dsuuetlon IrvPxilon By D.ro Common ACCOUNTING ONLY: AID' FACT PE CODES FEE INFO AMOUNT REMITTED HECK'/CASH RECEIVED SY DA E PERMIT/SERVICE REQUEST NUMBER INVOICE 8v 1n 73