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i A fAPPLICATION FOR WELLIPUMP PERMIT )t .; AN JOAQUIN COUNTY PUBLIC HEALTH SERVI 0 ENVIRONMENTAL HEALTH DIVISION r RID, BOX 38% 304 EAST WEBER AVENUE, STOCKTON, CA 901-388 (2091468.3420 �J NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM 4ATE ISSUEO ICompkt&In Trip#'ieatel 11 N. APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPUCATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT `TITLE,CHAPTER /9-1115.3 �-1 11 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. t y JOB ADDRESSOR APN# f r 0 r �flLl I , /Itwy"i+ /� � CITY 5`*�/"Ue f PARCEL SIZE/APN! OWNER'S NAME did-API Ceru�I, e!• ; — c it"IM4ADDRESS �. / I(�' cV�.+�Q L . �fl 6+ PHONEI��II�.r�� t` CONTRACTOR x771 GC GW-5CV"W4 11,,t ADDRESS (�^ [3YJf V:�?�I' f7ri'Wt4e' C^�Hr f SUBCONTRACTOR GrcS•! f'rIIIII'1'Ir-I'�LK)„�tl ADDRESS 750 44.E 1� Xlgr ) ez. UC* PHONE IF10-3 3- ti T a TYPE GF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL/ ' ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR VAPOR EXTRACTION WELL/ - J ❑New❑Repair H.P. OEPTH PUMP SET FT. "', - FIRST WATER LEVELQ k%L� O R #. YPE Of PUMP) 13.GUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL+1 I � SOIL BORENG _ ( _CVL.. Vy�. wo if a I ❑DESTRUCTION:, INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION& it A i. ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION OIA,OF CONDUCTOR CASING Q f ❑ GOMESTIC/PRIVATE ❑GRAVEL PACKMZE TYPE OF CASINGISTEEUPVC I OIA.OF WELL CASING O ❑ PUSUCIMUNICIPAL ❑��`DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAG 80THER 51 GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yr ❑No CONCRETE PEDESTAL By DRILLER:❑Yee ON. S APPROX.DEPTH L V '+ LOCKING CHESTER BOXISTOVE PPE // S {� PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER 11 CABLE OTHERekA -k-hKG[�jf I HE9ESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANC REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:9 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'&COMPENSATION LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR BUBCONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT 1N THE PERFORMANCE.OE_THE WORK.FOR WHICH THls.PERMIT I8-ISSVEDj4-SFkALL EMPLOY PERSONS SUBJECT TO WOMMAN'S COMPEN*ATION LAWS Of CALIFORNIA.- �APPUCAN.TM.Vg:j��FOR ALL REQUIRED IN=PECTtON&AT i20Y14e&i4Z3. CDMPI,ETE DRAWING AT L04Nfl1 AREA P1gVIDED.Slpmd X_ 71t1a C\I[/�IS �; ._ _._._Deter PLOT PIAN(Drew to Seete)Scale f r2 'to " - I 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. i'+ EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 9. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. SII STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. OWTHE PROPERTY OR ADJOINING PROPERTY. :. .. 65 1— — ...; .. . . .. rlwtl� uS'rs i :amu ...... . - - - DEPAIITMENT USE ONLY tApplleatlen Accepted By Date • l�a�. Area - Grow Impaction BY Date Pump Inspection By Onto Dertruetien Impaction BY Date _ f Comments: 1 ACCOUNTING ONLY: AID# FAC; PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PI6 MIT/40MCE REQUEST NUMBER INVOICE 35o l o 'L