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i APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-388 (2091468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED (Complete in Triplicate). APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALLTHE WORK DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPM[,ENT TITLE,CHAPTER 9.111 5.3 AND THE STANDARDS OF SAN JOAGUIN COUNTY �•PUBLIC JHEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION, JOB ADORESSIOR/A"m 3/`•�-1 3•, G , Ch er_ok e/P�' 1�el y C S*coo G/v�}o J� PARCEL SIZEIAPN& '7 �/ OWNER'S NAME C2CCA f>�1 CSC Cali J)1 L.. I'7F�JCvK,_ADDRESS - 6)12-19 I``T'!T Am�(J C- 6 PHONE I 5W)-- / -V-20�O CONfRACTD .Spe �i L�M1 F�(nro�{.h.(}'H /"OoFtEBS !ZO Z. 11' jYl.-?Y! 6e LICA 11f�f� PHONEiz�'�c,v} .0'�K� NTRACTOR ADDRESS /! ��n t'/5 S7C.3 uC/ RfONEI TYPE OF WEL.l1PUMP: EW WELL ❑ REPLACEMENT WELL MONITORING WELL R V> �1 y ❑ OTHER ❑ INSTALLATION' ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EOKTRACTION WELL R J 13N.11Repdt H,P, DEPTH PUMP SET FT, FIRST WATER LEVEL i O (TYPE OF PUMP( ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL 1 ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION$PECIACATLONS �� A 13INDUSTRIAL 13OPEN BOTTOM DIA.OF WELL EXCAVATION l' DIA.OF CONDUCTOR CASING / 0 L. 3 13R DOMESTICIPVATE GRAVEL PACKISIZE�� TYPE OF CASINOtSTEELIPVC !/G DIA.OF WELL CASING O ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL&O _ _.. SPECIFICATION C tt R ❑ MRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY S�rmi)Yr) GROUT BRAND NAME E 1U{J MONITORING / GROUT SEAL PUMPED: 11 Yea)i6-le � CONCRETE PEDESTAL BY DR/IILLLFEY-Yee ❑Ne S APPROX DEPTH_ q l/'� LOCKING CHESTER BOXISTOVE PIPE 2 I'lll'S h PROPOSED CONETRLPCTIOMMMLLNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT!HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN 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 SUB-CONTRACTING SIGNATURE CERTIFIES ^ THE FOLLOWING: L I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF `\V CAUFORNIA.' HE APPLICANT MUST 1CALL �24 HH/OUR,S.IN ADVANCE FOR ALL REQUIRED INSSPPEE��CTIONS AT IZDei 488-3422. COMPLETE DRAWING ATLOWER AREA PROVIDED. '7 � 11 W¢nad X _ _ i/V r f/i` lY- Thle�1 _ ...._ Det- - PLOT-PLAN Ot.w to Soekl Swtle 'to gy . 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 OIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. J. 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 WALLS. ON THE PROPERTY OR ADJOINING PROPERTY. Ch ... ...........:... DEPARTMENT USE ONLY 9 < Applleatlon Accepted By Oete { Arae \ Great lnpaction 8YDete PL-P I-P—on BY Dete D-tructlon Impacrien BY Det. Comment,: /' 15 .A Z c� �-,3. t i� '�e. /�►�� -- --- ---- ACCOUNnNO ONLY: AID* FAC/ PE CODES FEE INFO AMOUNT REMITTED CHECKSICASH RECavvp BY DA PUMIYISOMPF REQUEST NUMBER INVOICE �� .3rp 3 9s moo sw • lJ •