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�(0, 'mow, APPLICATION FOR WELLIPUMP PERMIh' C 1 a SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION LA P.O. BOX 388 304 EAST WEBER AVENUE, STOCKTON. CA 95201-388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED: (Complete In Triplicate) J ` ` '� l ' 52 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 COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS // OR APNI Lp �D W. C N.r7�t/` JAJ t`/ CITY S+G C-k+0✓1 PARCEL SIZE/APNI OWNER'S NAME I=q V dOn En 4ee i S f,s L L C- ADDRESS PA 66-K 4 d qq C.,J,n 6A CIL)7V? PHONE N . y J CONTRACTOR CA E r v i r o n M-e.-+ ADDRESS_ ox .2 S2;��/ L/4 UCS! PHONE 076-2-93117-119S-0SUB CONTRACTOR /'e 7 5 i/�'i I r ''�7 ADDRESS9S b A/ ,e Ad. /-(w��.'r`a 2 UC+1 PHONE I x,25 313•S-QpG TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL N ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLI J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑,OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I T _ SOIIL BORIN/G� ri h S 8 ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC DIA.OF WELL CASINO O ❑ PUBLIC/MUNICIPAL ❑LJ/DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R �❑ IRRIGATION/AG OTHER /3u..tr.` GROUT SEAL INSTALLED BY GROUT BRAND NAME E G3 MONRORING // GROUT SEAL PUMPED: ❑Yee ❑No CONCRETE PEDESTAL SY DRILLER:❑Yw ❑No S APPROX.DEPTH S V' 1?0 LOCKING CHESTER BOX/STOVE PIPE /' S PROPOSED CONSTRUCTION/DItlWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER vGere 1 HE"Y CERTIFY THAT 1 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 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 19 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF.THE WORK.FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT VST CA HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12081461111-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slpned X TitleDate� PLOT PLAN IDrew to Scale)Seale 'to 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. 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. ---- . A .