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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEt, ENVIRONMENTAL HEALTH DIVISION �( P4 OX 368, 445 N. SAN JOAQUIN ST„ STOCKTON, CA 95201-388 (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompha in TrIpIkea) APPLICATION Ii+HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPUCATION IS MADE IN COMP-IANCE WITH BAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARD'OF SAN JOAQUIN COUNTY R/,Bl�l/C//HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADOFIESSJOR N'NI__1 �+ .� ( F7 Df T p ti•` I�VI - CRY �O lL ! PARCEL SQE'APN/_ OWNER'S NAME ✓✓t/[`. IC�,F,a,C- ADDRESS ,S .M� PNONF I CONTRACTORg_�_ ADDRESS c.. V'L uC/3 r _PRONE SUB CONTRACTOR _ ADDRESS LIC/ PHONE# TYPE OF WELVPUNIP. ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER ❑ INSTTA-LATION ❑WELL STEM REPAIR ❑ CROS&CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑New IG r HP DEPTH PUMP SET-��FT. FIRST WATER Lr_NEL_r 6 O RYPE OF PUMP) ❑ OUT-0FSERVICE WELL ❑GEOPHYSICAL WELL I ❑ SOIL BOPING B ❑DESTRUCTION: INTENDED USE TYPO OF WELL CONSTRUCTION SPECIFICATION* A S❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA-OF CONDUCTOR CASING O 16l DOMEEmcfP MVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGMTEEUPVC DIA.OF WELL CASING D 13PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PLUMPED:❑Yw [IN. CONCRETE PEDESTAL BY DNLLE'A:❑Y— ❑N. S 1 APPROX.DEPTH ( ( v LOCKING CHESTER BOX/STOVE PIPE_ S W PROPOSED CONSTRUCTIONA RILLINO METHOD: MUD ROTARY_ AIR ROTARY AUGER _CABLE OTHER 41 I HEREBY CERTIFY THAT 1 HAVE PRFPA/Ep THIS APPLICATION AND THAT THE WORK WILL BE GONE MJ ACCORDANCE N.'RH SAN JOAQUIN COUNTY ORDINANCES,STATE UWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALJFOANIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: ' ERTWY THAT IN TTM:PE MICE THE WORK FOR WHICH THIS PERMIT IS ISSUED,I?MALL EMPLOY PERSONS SUBJECT TO WORKMAN'*C N LAWS OF ' CALIrANA E ANT MUST CALL IN MICE FOR ALL ITEOIARED INSPECTIONS AT 1=0111)IM4423. COMPLETE DRAWING AT LOWER AREA R10VIDED. Bkn.6 X 711t. ��1r MAT PLAN 10'—to S.W-1 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED jO,yll 2. OUTLWE OF THE PROPERTY,GIVINO DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3, DIMENSIONED OUTLINFS AND LOCATION OF ALL EXISTM/G 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. ........ .............. .,.. ........ ..........,.- t tP c�................... ....... ........ ......€..... PC :...:................. . '. ............ X199.' .. ... '. . .,. •-- ; 3:Ily JG� r Rot" E;J ItAL'PN StI t,!:;C' 1`'fitl� ..;: .1 A . . . ...................... . ........ . .'h . :.....F .. . ................. .... .. . . . ' \ : . . .. .... �.*�/ ......................... .... . DEPARTMENT USE ONLY p(/q/L� ApPL..ti.n A—Fted BY---ie. -IBJ L/ �/�I•W�J�_. �� /-rY. �-/•� 1 .Ara. 7, 1 #_ Grain 1--k..By_ Uete P—P 1—ti—Br DASM1Vet1.n Nvp—ion P.Y Dele COTmanF: ACCOUN:INO ONLY: ND# FAC# PE CODE* FEE INFO AMOUNT REMITTED CHECK# ASH RECEIVFD BY DATE PERMITISERVICE REQUEST NUN*9L INVOICE Oscoo 1-7LIWI 0,,7q�,5 !L DSD /d I