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APPLICATION FOR WELL►PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICLS ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388,445 N.SAN JOADUIN ST,STOCKTON,CA 95201.388 (209)4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compleu i8 Tripfieftf) 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--}n7/11155.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/ORAPN._3730 MII.I1 ib,—d Ave-VSCITY s4o(Offi ((^^ ^L']+� f� PAFCEL SIZE/APN. OWNER'S NAME/� `1 J 'L sY1S ,.ADDRESS ^-�I3)fA1.A6d[ h4e/e- ggNEI 1` -3 (*()bS CONTRACTOR V(�ro L/�j d ` A�P�Ot� jl /�h 1 ADDRESS PJAI W.I &I t ch. LICI 1 1PHOME.9/S1-f3�-'/p 1 SUBCONTRACTOR �Otl�V4L...AYIO Cm IN-Ca ADDRESS ~ IJCI��LONEI�IA��+�I� -fwcV�.� JrTC� TYPE OF WELLIPUMP. ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL. ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELLt J ❑New❑Repelr H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL p TYPE OF PUMP) ❑OUT-OF-SERVICE WELL /❑GEOPHYSICAL WELLS I.',�(r fit❑ SOIL SORIJNyG�., XDESTRUGTION: � �`A/"l �t•At Ll We A� `r/� �rlc-i.C._. (/[I l 661-3 �'� r t't�v`(✓\ INTENDED UTE TYPE OF WELL CONSTRUCTION SPECIPCATIONf A ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTORCASING D ❑DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASING/STETUPVC DIA.OF WELL CASING D ❑PUSLICIMUNK.IPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION N ❑IRRIGATWN/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑MONITORING GROUT SEAL PUMPED:❑Y- [IN. CONCRETE PEDESTAL BY DRILLER❑Yr ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONBTRUCTION/DgWNO METHOD:MUD ROTARY AIR ROTARY AUGEfl 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 JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'H CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FDR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.'T M TEIS CALL F---IN ADVANCE FOR ALL REQUIRED INy/SP�ECTIIO,.-AT 1-11/W'-2/3..COMPLETE DRAWING AT LOWQL A—PROVIDEp. Slyrrd X M Lf�(A�'MTtH 1 1 L.�L LJ`�� sne-aIl!�t DHA r°/�_ PAT PLAN LD—to Seelel 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. Date /}� Applllon AmepteE 8Y IR Q[� a� ARTMENT UBE ONLY utrr� A, N �_� Grout Imp-tlon 8y Dete Pump lmp-tbn By Dete Dmtruotlon Impeetlon By Dete Cemmente: ACCOUNTING ONLY: I FAC. PE CODES FEE INFO AMOUNT REPNTTED CHEC"MASH RECEIVED BY DA E PERMITISE VICE AEGUEST NUMBER INVOICE 51120. uf