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S'41SPPLICATION FOR WELLIPUMP PERMIT OAQUIN COUNTY PUBLIC HEALTH SERVICES . ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201388 (209) 4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in TrplirAtel .PPUCATION 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 COMPLIANCE WITH SAN OAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS`RDS OF SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. OB ADDRESS/OR APNY 61 7 ' iGL"` ` 1Cil P_ CT C7 I PARCEL SIZE/APNI -- - PHONE# IWNER'S NAME ADDRESS LIU PHONE/ _-- ONTRACTOR `1 ` -t (� �y� �"l V/ ,�i y\CL ADDRESS l C Z� C - F�' f �[' C. UCl PHONE J' �Z '1B CONTRACTOR ��.'•'� 'PE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ¢L MONITORING WELL R J ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL Y ❑Nev❑P.e,eir H.P. DEPTH PUMP SET---FT- FIRST WATER LEVEL 0 YPE OF PUMP( ❑ SOIL BORING S ❑ OUT-OFSERVICE WELL C1 GEOPHYSICAL WELL! 11 y 1, ,r r•z�-� l,1 DESTRUCTION: L� J \ (`� { K C- r r• 1 A i ENDED USE TYPE OF WELL CONSTRUCTION SPEGIFICATIONH 1 DIA.OF CONDUCTOR CASING INDUSTRIAL DUBiflIAI OPEN BOTTOM DIA.OF WELL E%CAVATION !`" 7 OOMESTIC/PBIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGIS EE DIA.OF WELL CASING Z , D SPECIFICATION R PUBUCR.IUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL ] IRRIGATION/AG El OTHER GROUT SEAL INSTALLED BV GROUT BRAND NAME E GROUT SEAL PUMPED: ❑ ❑Fl Ys o CONCRETE PEDESTAL BY DRIUER: No ❑Y. ❑ S MONITORING S� 'PPLO%.DEPTH LOCKING CHESTER 80%/STOVE RPE 'OPobm DItlWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER J CST r'c: 'u.'\ �E4EBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION ANO THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOADUIN COUNTY ORDINANCES.STATE LAWS,AND PULES AND GUEBY CER OF THE SAN AVE PFJOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH .IS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTMCTING SIGNATURE CERTIFIES 1E FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANC OF THE WOW FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF� tUPoRNIA.' T A /CA'NTCCM[UB�CALL 34110UR8 VANCE FOR ALL REQUIRED INSPECTIONS AT 130Y11 ASSL;,Nn COMPLETE DRAWING AT LOWER AREA PROVIDED. (�C✓r C : / - _ '` ' TLD. r `L✓S \ / 1 c '1 C. D.I. Z. Lu X15 PLOT PLAN 01.to SC eI SWe 'to ]� e. LOCATION OF MOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED U NAMES OF STREETS OR ROADS NEAREST TO OR ROUNDING THE PROPERTY. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. XIY DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED ON THE PROPERTY OR ADJOINING PROPERTY. y STRUCTURES.INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVE,AN`WAw ty DEPARTMENT USE ONLY eollwtlon Aco tP BY. ,/ By. Dem Are. t/L//1 ,ul Irr,ecilon BY V Dam Pum,Iro,atlon BY Dae VV Dae 17 �[rw[wn Irvl>.c[ianAey m nmt.: ACCOUNTING ONLY AID# FACT PE COD" FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE ONA