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� APPLICATION FOR WELLIPUMP PERMIT N JOAQUIN COUNTY PUBLIC HEALTH SERVIW ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (209) 468.3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CDmpkb in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1,1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN#� III �IQVU DYIVP. CITY S-I'OCk f(m /� L / PARCEL SIZE/APN# �63-2G 0-07 OWNER'S NAME S Gw6L lINf, ADDRESS +t tjrjCSUI� 04 k 6tA Gh PHONE M$/019S/-3670 CONTRACTOR K� �S.50G. ADDRES6 4 U/. Dr Le Ht A✓K/ A�hy"; C& LICK 4{[f(rl(29 PHONE#' cv/3qx-22-vv I SUBCONTRACTOR AVI.IL O ENV. AC1 1✓15 V)C— ADDRESS'I431 Rf5t6 k Art. FGHf4HA uC# 647349 PHONE li*351-- ) r� TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL K OTHER CPT If 4ti r"(/k ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL K ✓ ❑Ne c❑Repair H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL O (TYPE OF PUMP) // ,,LI'� ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL K � SOIL BORING 75 ,4olIAL✓ Sa)'MT ryw.T#r g 11DESTRUCTION- INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS / A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION,-9.S"CPT • 75/AMBSP DIA.OF CONDUCTOR CASING J/� D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/`SIZE TYPE OF CASING/STEEL/PVC� - DIA.OF WELL CASING 'V" o D ❑ PUBLICMNUNICIPAL IXDRIVENI!p—1)\ DEPTH OF GROUT SEAL SUY:a u. -Fv Ae% bn{kA+� SPECIFICATION ,VSA g ❑ IRRIGATION/AG ❑OTHER J GROUT SEAL INSTALLED BY 'Tit H71'/_ GROUT BRAND NAMES ndlGUgp a SlG✓Y 4 E MONITORING GROUT SEAL PUMPED: COY. [IN. CONCRETE PEDESTAL BY DRILLER:❑Va [IN. S I APPROX.DEPTH 'f Ci C P:[t .20 I A4 Aty- LOCKING CHESTER BOX/STOVE PIPE 4�& S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER k CABLE OTHER ep r dIOP941CH, Cor Sc lI SQ.N,plts I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW 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 WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I 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 MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120111) S 423. COMPLETE DRAWING AT LOWER AREA PROVIDED. sioneaX :4411A fA �, n/� Tine Lr6jr'cj- Data Q//S/�i'�. PLOT PLAN (Dnwc to S .)Sul. '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 OUTUNFS 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. .......... / j/[/E/�+ I/�p��_/�AA 11/ ... .. DEPARTMENT USE ONLY Application Accepted By Data ` • Ara Grout Inspection By Data Pump Inspection By Date Destruction Inspection By Date Comment.— ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED �/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 3S o 9 �k 6 3