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APPLICATION FOR INELLIPUMP PERMIT USAN JOAOUIN COUNTY PUBLIC HEALTH SERVIOd ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (compiets in APPLICATION IS HERE By 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,CH.A/PTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY MOM HEALTH SERVICES,E(N(f�R(/W NTAL N IVISIOgH 'l JOB ADDRESSOR APNr J ` —'UK c? lh/ cm (} -3 J/"• XW W F��yV ` PARCEL SIZE/APN of OWNER'S NAME �--�r� s /C/IK7�V!• I'W" / _ �)Awv.T; PHONE r CONTRACTORS L✓ oe� j�— - ADDRESS - //✓- (_'.�.L �..' S%n LIC, 5-5-5;5-- SUB CONTRACTOR L^ r li .4v ADDRESSZY25I��rZ.a A4_ C /{✓T-, TYPE OF WELLMJMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTg TWN WELL ❑New❑Repeir H.P. DEPTH PUMP SET Ff. FIRST WATER LEVEL TYPE OF MMPI FIRST , O ❑ OUT-OF-SERVICE LL ❑ GEOPHYSICAL WELL 1 pL SOIL BORING C./�/f//dAdlJ'v"`.e`r s 11 DESTRUCTION WE INTENDED USE TYPE OF WELL CONSTRUCTION bPECIFICATIONS N A INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION / j., DIA.OF CONDUCTOR CASINO N�/t D ❑ DOMESTIC/ VATE ❑AA GRAVEL PACK/SIZE TYPE OF CASING/STEEVPVC It✓3rlc7 DIA.OF WELL CASING D ❑ PUBUC/MUNICIPAL LNFORIVEN DEPTH OF GROUT SEAL �V KFT— SPECIFICATION t�� r t1'Y/ R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY /[C/r I/f GROUT BRAND NAME SCC S V E MONITORING GROUT MAL PUMPED:$3 Yes ❑No CONCRETE PEDESTAL BV DWLLLR:❑yes 0,114, APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTIONNWLUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER&V i/tW 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: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISS O,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE MUDI C IR'THAT IN THE PERFORMANCE OF WORK FOR WHICH THIS PERMIT IS ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNI THE APP CANT MUSTCALL HOURS IN AO LCE FOR ALL REQUIRED INSPECTION&AT U109)4883 M. COMPLETE DRAWING AT LOWER AREA PROVID BIy1Md X- /� � ' tsL 4 Tltla Ut O:.00c/S PLOT PLAN (Draw to Scolal Sub 'to 1. NAMES OF STREETS OR ROADS NEAREST TO Ofl 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 OUTUNF.S AND LOCATION OF ALL EXISTING AND PROPOSED 6. 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. ��[E��y]1(/��Fy'1/n) DEPARTMENT USE ONLY Application Accepted By_�/1 '- `�f " I �AfL� Dot. l l� ALL Ara, Grant Impaction By Date Pump Impaction By Date Destruction Impaction By Deto Comme,w ACCOUNTING ONLY: AID# FAC# PE COD" FEE INFO AMOUNT REMITTED CHECK#ICASM RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE