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• • APPLICATION FOR WELLIPUMP PERMIT . AN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201388 (209) 4683420 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 AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPME T LE CHAPTER 9-1115.3 AND THE STANDARDS j S� �N JOAGUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. Y,� JOB ADDRESSRHFARNK // - hC�r CITY LCCv PARCEL SIZElAPNK OWNER'S NAME LA ✓ ' t 1c-)' t ADDRESS /J T \ f 7 / r/�- ✓OJYGez 4'eVo CONTRACTOR 6SK t /7 SfOC�a PS ADDRESS /.9/ Q l7n P%Prrro.#dxlC;r PHONE I SUB CONTRACTOR ADORES S ppII UCCK PHONE K TYPE OF WELLIPUMP: ❑ NEW WELL CIREPLACEMENT WELL ❑ MONITORING WELL K iC4 OTHER 90/e-h0/e /e✓Aiea oe7e1�s O G ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL K ❑New❑Ree.ir H.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL 0 (TYPE OF PUMP( , pI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL K IQI SOIL BORING ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS p A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION !/ DIA.OF CONDUCTOR CASING O ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELA C �2" OVG DIA.OF WELL CASING O ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 5"f r SPECIFICATION R RR❑11 IRRIGATION/AG ®OTHER GROUT SEAL INSTALLED BY Geev'pe'& 1e1/dfS GROUT BRAND NAME E ILS MONTTORING(F/al A"7 e) GROUT SEAL PUMPED: ❑Vs [IN. CONCRETE PEDESTAL BY DRILLER:❑Ys [IN. S APPROX.DEPTH f 4WOSe nO–1?-5 T LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTIONRXSLLING METHOD: MUD ROTARY AIR ROTARY X AUGER 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:'1 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 CAUFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'' THE APPLICANT AMUST CALL M HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT OHM)4p411423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Sl'r X /// ( /L/^' TItI. C�YD(Of�S D.t. s [J PLOT WAN [Dr"to Sc a)Scale 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING 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. ...i...... ._....;. .. ....i.. .. ... ._...._._ z 1 L..... ..._. .....i,. ......i... ...... ...: ........'. a I ...i....... ..i .. :............ - i.:..A. ..i _.<....... . .. .. .. ..b.. .. . . ..