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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAOUIN ST, STOCKTON, CA 96201388 (209) 408.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Mompleb In Triplicate) ATPLIOATION IS HERE SY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDAIR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3,/ AND THE STANDARDS OF SAN JOAQUIN COUNTYyPMUC HEALTH SERVICES,ENVSpNMENTAL HEALTH DIVISION. JOS AODRESS,OR APNE Z SS -106 -O ' —CITY 'Ti Y PARCEL SIZE/AI N OWNER'S NAME Cbzu , aryl Mi MT niahi ADOREss 1600 W. anhu Foxy RIONER 835-3596 coNTRAcroR V R W Tl-illirrr ADDRESS P_ n_ R S1,T2in Victr$B 722X104 PHONE 47071 5 SUBCONTRACTOR y� ADORES S CA 94571 LIG PHONE# TYPEOF WELLA'UMP: ❑ NEW WELL ❑ REPLACEMENT WELL K7 MONITORING WELL tis ❑OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS ONNECTREPAIR ❑ VAPOREXTRACTIONWELLE J 11 N. ❑Nwt, H.P. DEPTH PUMP GET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUTOFSERVICE WELL ❑ GEOPHYSICAL WELL P ❑ SOIL BORING B ❑GESTRUCTION: INT04DED USE TYPE OF WELL CONSTRUCTION SPECITICATIONS A US ❑ INDTNAL q❑I OPEN BOTTOM DIA.OF WELL EXCAVATION 8.5DIA.OF CONDUCTOR CASING D ❑ DOMESTICIPPoVATE IcI GRAVEL PACKISIZE44-3 TYPE OF CASING/RTEEtJFJC 40 ICYC DIA.OFWELLCASING 2" O ❑ PUBLICMUMCIPAL ❑DRIVEN DEPTH OF GROUT SEAI.__TC1TTI Rag. SPECIFICATION R 0 ORI� GROW SEM.A ❑A OTHER INSTALLED PE My. ❑Ne � F CONCRETE DESTAL BV DR LLER O ❑Ne s APP110OL GERH 20' & 40' IOCKIND CHESTER BO%/BTOVE RPE 11afic H7}' s MINI NED CON 1111UCTONIOW W NG METHOD: MUD ROTARY AIR ROTARY AUGER Ll-- CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APRICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO 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 IB ISSUED,I SHALL NOT EMP Y PERSONS SUBJECT TO WORILMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SU& ONTRACTING SIGNATURE CERTIFIES THE FO O: 'I CERTRFY THAT 11 PERFORMANCE OF THE WOW FOR WHICH THIS PERMR IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFO11�1T K AMIIC 1 MIN C SS HDIXIB IN ADVANCE FOR ALL REOM M10 JNS E TIO T 13W14ESi42i. COMPLETE DRAWING AT LOWER AREA PRO DEO. SIBIIpM l[ title L �'O``ll//1.(/l.Ld. ROT RAN ID—t.So.l.1 S. 3�•ro AN I 1. NAMES OF BTREETB OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISROSAL SYSTEM OR PLiOPOSED 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE MSFKUiAL SYSTEMS. 3. DNFHBIONED OUTUNE6 AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY IT. 87TUCT11RES,�INDCLLUADIIINNGG,TC�O�VA,ETRREETD AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE FRORRTY OR ADJOINING PROPERTY. SEE ......o-.... . .v ..i.....3....: .a. ........c.....' a .......o....i. ... '... .. ..... .. ...... 4......�.. .. ........ ..i v.... ... ...... .<......:... O .. '. .a....:......4...... .4. ..:.....4 ....y W A. W Br1 •♦Y I (V DEPARTMENT USE ONLY Applk D.ts I f L � / Nm Grout INpp.t BY mt. P p lmp i.n By DSM DSVNp11.N BIppE.N.O BY Dete T.e,nlne,Ie: ACCOUNTING ONLY: NG FACP FE CODER FEE INFO AMOUNT REMITTED CHEC"fCASH RECEIVED BY DATE PEIPUTISERMCE REQUEST NUMBER INVOICE