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APPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAOUIN ST., STOCKTON, CA 96201-388 12091 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUER ICompletn in Tripliutbl APPLICATION 18 HENS BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WRIT SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11115.3 AND THE STANDAROS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH ot"mN. JOB ADDPESMR/��IP 1NX IL7�' O15/ /.— UZ-1 cr-Y s;cl . 2,.� PARCEL SUVAPNX OWNER'S NAMLV ,,',.C.. L-�' IN, �i( Af-'L J ADDRESS 61901 OdI I l"g PHONE• CONTRACTOR �/'� IyVG(i Ci0/.�. L AO011Es6 AGGREss�^T52/SIIE: WPIC/�/6 L1,i'— /j IV[� IICX�-T� l3 RgNEX SIO -_[b}Q�I�l e [4 JCXSlPHONEsue CONTRACTOR - TYPE OF WEL MP: 0 NEW WELL ❑ REPLACEMENT WELL ❑ MONRONNG WELL/M�_� ❑ OTHER El INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL X J / ❑New❑Repar H.P. I. DEPTH NMP SET FT. FIRST WATER LEVEL O 1 v` (TYPE OF NMP) _ `R ❑ OUTaF-SERVICE WELL ❑ GEOPHYSICAL WELL X ❑ SOIL BORING S ❑DESTRUCTION: ^, INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS At `'I� A �M( ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION el DIA.OF CONDUCTOR CASING IWN O ❑ DOMESTIO!PRNATE ❑GRAVEL PACKISIZEfiL 50r4k TYPEOFCASINGISTEELPJC DIA.OF WELL CASING II IID ❑ PUnIIClMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL - SPECiflCAT10N ❑ IRFIGATKINIAG ❑OTHER GROUT SEAL INSTALLED BV D/, �.I/� GROUT BRAND NAME E MONITORING GROUT SEAL PUMPED: 13 y- N. CONCRETE PEDESTAL BY DRILLFR: Ys ❑Ne S APPROX.DEPTH Y J .rU LOCKING CHESTER BOx/STOVE PP: S PROPOSED CONSTRUCTONRNOWNn METHOD: U.ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORt WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND REGULAMNS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFO WANCE OF THE WOR(FOR WHICH THIS PERPAIE 16 ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSAT)N LAWS OF CAUFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNAWRE CERTIFIES THE FOLLGWI '111 CERTIFY THAT IN THE PERFORMANCE OF THE WOIK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA H APP ICM MWT LL 3A N04PS I ADVANCE FOR ALL REQUIRED INSPECTON&AT 1305 AgJ.ME COMPLETE DRAWING AT LOWER AREA hPRROVIOED.'? s'aRw x TB. !-4 N.'A/a A-ted IQ4A I/ D.I. I f Ind !_ PLOT RAN IM.to S .l SW. R 1. NAMES OF VFEETh OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. S. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANBKIN OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES 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. .. .. DEPARTMENT USE ONLY A Pu-11..Accepl.E Br D.I. Nu cmm ImosnP.By D.w Pump I��nP.By,D.m D-1-1.Inp.cllen 8r D.I. Cammen[c ✓ ACCOUNTNO ONLY: Mpf [qC/ P=CODES FEE INEO AMOUNT RENOTTED CHEC"XCASH RECEIVED BY DATE NI PNIT.EYVICE REQUEST NLM89t INVOICE O -2, LQ