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APPLICATION FOR WELLIPUMP PERMIT --'SAN JOAQUIN COUNTY PUBLIC HEALTH SERVIe!e, ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDMSS/OR APPNN' SOS N� psCcZ C./Y'V C CITY NT^OQ/� PARCEL SIZE/APN# �1�AC/L 4:7- OWNER'S NAME K�74C.F/7�vclYO /lO�Tlb/.r�—/t-NN G RION�KpO��GS CONTRACTOR 1/A^Y/F /�- �/p0;; ADDRESS/+J/VR�o cc F4c ST//" UCN S�/S— PLK1�Iy(E"'A� ^yJ/,_ SUB CONTRACTOR G�JZ El�v"J 7-."'�iv L� ADDRES6f 7y � GC�/yP t1_(,TD S1IWc UC 5'43K437 PHONE I V1 Jul TYPE OF WELUMMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL X ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 0 J ❑New❑RepeV M.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 (TYPE OF PUMP( ❑ OUT-OF-SERVICE WELL ❑ GEOPMVSICALWELL# 801LBOPoNGGQT�/fY,0A IP✓NGN` B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS / #, IV/ A 11 INDUSTRIAL INDUSTRIAL OPEN BOTTOM DIA.OF WELL EXCAVATION /�1', DIA.OF CONDUCTOR CASINGC+Vd D ❑ DOMESTIC/PRIVATE 01�GRAVEL PACK/SIZE TYPE OF CASING/STEELP C � DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL L#�DRIVEN DEPTH OF GROUT SEAL Sa 'FI SPECIFICATIONAI�o4rtYyf3� vT R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BBp Y Thi c GROUT BRAND NAME P--TX+4+D E MONITORING GROUT SEAL PUMPED: RY. [IN. CONCRETE PEDESTAL BV DRILLER:❑Ys ON, S APPROX.DEPTH LOCKING CHESTER BOXR OVE RPE5 PROPOSED CONSTRUCTIONMRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER`/�^JJ L�✓e" 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: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL HOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWIN I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT I6 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFO THE AYPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120014683423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slor X � 1 TItlo LYCa Gtif, i i Date /V(. PLOT PLAN (Dra to Sw o)Scale -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. V �EyPMTMENT USE ONLY AppliWion Accepted BY /1 1. l/1 /� -wt. Goin Inepecron By D,te Pump Inspection By wte Drotruction Inpec[ion BY Date commenu: .7 Y ACCOUNTING ONLY: AID# FACA P£CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY D TE PERMIT/SERVICE REQUEST NUMBER INVOICE 8�/ 0 LJ� 13 `1S 0 7