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APPLICATION FOR WELLlPUMP PERMIT .AN JOA01.-'BOUNTY PUBLIC HEALTH SERVI EN►%meMENTAL HEALTH DIVISION P 0 BOX 388,445 N.SAN JOAOUIN ST.,STOCKTON,CA 95201-388 (2091468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MamRlots in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, PI JOB ADORESSIOR AN /_ G d'3 So u,;-,q S%J1&E`I— CITY .J- /� //�� _ / PARCEL 912E/APTII p OWNER'S NAME GFT J rn Q' N ADDRESS I G-JIU PHO CONTRACTOR g-1ZP3 CONTRACTOR j {wADDRESS rPHONES SLBCONTRACTOR A JLW ADDRESS 2,3LICI`S— PHONEOki- ^-`J?S3P2'^�4J� q TYPE OF WELUPU/P: X NEW WELL ❑REPLACEMENT WELL ❑ MONITORING WELL N ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR VAPOR EXTRACTION WELL►VLL J RVPE OF RfMPI ❑Naw 11P Rw.I, H,P. DEPTH PUMP SET FT. FIRST WATER LEVEL O, O 11OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL* ❑ SOIL BORING g 13 DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTIOM 6PEOIFlCATIONS 1��EE A Q INDUSTRIAL ❑OPEN BOTTOM 7 DIA.OF WELL EXCAVATION IO t DIA,OF CONDUCTOR CASING ✓-11 y D ❑DOMESTICIPFIIVATE ❑GRAVEL PA�CIfK/��S�I�Z(E. 3 TYPE OF CASMG/STEEUPVC !-IIG DIA.OF WELL CASING Q ❑PUBLICIMUNICIPAL 9❑�DRIVEN -a'Tuf�L? S.4.3A DEPTH OF GROUT SEAL SPECIFICATION p ❑IRRIGATIONfAG pIOTHER J GROUT SEAL INSTALLED�BY � NRZAW)fT GROUT BRAND NAME E I MONFTORINO GROUT SEAL PIMPED: py_ ❑Ne CONCRETE PEDESTAL 8Y DRILLER: Y- ❑Ne S APPRO%,DE►TN.. BOO J�LCE� LOCKING CHESTER SOX/STOVE PPE S. PROPOSED CONSTRUCTIONIDRfWNG METHOD; MUD RDTARV AIR ROTARY AUGER X••�CABLE 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 JDAOVIN 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,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' COWFRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERrIF1ES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE AWT MUST CALL 24 HOIMW N ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091 44W4427. COMPLETE DRAWING AT LOWER AREA PROVIDED. SlpneC '/ Title ��Ll J5'1 G.ST /,1&7 PDT PLAN IOInw to 6eMal Swle 'ee NRZrNeT 1. NAMES OF STREETS OR RO S NEAREST T O OUN04NG THE PtOPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2.OUTLINE OF THE PROPERTY,GIVING DIME S ANO NORTH DIRECTION. E%PANSION OF SEWAGE D15P06/4L SYSTEMS. J.DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 5. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJORNING PROPERTY. R�FE4 "/-/w .. . .. .. . .. .. ..... . . ...... DEPARTMENT USE ONLY AP16-11 n Ae NNI fl"_)" yDate IVs 35 0 Gloat Ir pectfan BY ON. T� PumP IMpactlan BY ON. Dsttuetlen Inpettien BY D4ta CommanN: ACCOUNTING ONLY: AIDN FAG! PE CODES FEE INFO AMOUNT REMITTED CCHrnHECK#fCASH AEyCPE]VEED�BY DATE PFRMITISERVICE REQUEST IN SIR fNVO10E v1- !( N