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APPLICATION FOR WELLIPUMP PERMIT ziAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAOUIN ST., STOCKTON, CA 96201 .388 (209) 468-3420 MON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUER (Complete in Triplicate) APPLICATION 15 HERE By MADE TO THE SAN JOAQUIN COUNTY FOO A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION IS MADE IN COMPLLANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLLEs CHAPTER 9-1115,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDNESSIOfl APNS " J L� 1 / �14 kr M �. RSP CRY C51 y`-' c/l 7bLA PARCEL SIZE1APNN OWNER'S NAME 1 0 1I �CC�t'C/�-I /l-C'_ /S!(��) L ( / / ADDRESS � _ ' 1C; [.�� PHONEN !' �y �T { CONTRACTOR SLU11 17/1 H/1 li(17�/1 A.L-F/n 11/ ��'-P I 1 lCl(�� : ADDRESS 1 / /V / V V1 t �l t , l—JW ""rJCN PHONEE��vT-/) � `3 3 U / 9 SUBCONTRACTOR S Ynlnl� I7o�1 ^_ ADDRE36236�.�lNA/ .Sjoc/ObRLN S 22- PHDNEN�/:.S �iZIZ I 1 TYPELJ OF WEUJFNUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL #.2q ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELLN J ❑ New ❑ Repair H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL 0 ` 1ttPE OF PUMPI tcs .-e// /1� �� {j❑ OSI jUT-0LF.SyER1VICE WELL(' I1�, ❑ GEOPHYSICAL WELL N�/'� {1�I,❑ SOIL BORING 9 LJDESTRUCTION: I IV 4L1 • ' 7l.Vll/ \ C)1" WI/-I�'I��/�� /�Jr�r Jro�W� • ��INr�'24I�r- INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS F � A ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION _ ( Ad- A DIA. OF CONDUCTOR CAGING O { ❑ DOMESTIC/PMVATE ❑ GRAVEL PACK/SIZE TYPE OF CASINGISTEELBWC G T (/C. DIA. OF WELL CASING D ❑ PIBUCDNUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL 0F:77— io5. 7EL SPECIFICATION N ❑ IIWGATIONIAG ❑ OTHER GROUT SEAL INSTALLED BY j5)( Lr zI 1 �C A GROUT BRAND NAME E ❑ MONITORING J GROUT SEAL PIMPED: ❑ Ys ❑ No CONCRETE PEDESTAL BY DRILLER: Vs [] NO S rWPI DEPTH ! LOCKING CHESTER BOX/STOVE PPE 3 WOMBED CONSTRUCTONIOPoWNO METHOD: MUD ROTARY AIR ROTARY1 AUGER CABLE OTHER 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND W REGULATIONS OF THE SAN JOAGUIN 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 OMMCTING SIGNATURE CERTIFIES THE FOLLOWING: ' I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{ COMPENSATION LAWS OF CAUFORNIA.'//' �''T��HE APPICANT MUST C LL 34 HOUIe IN ADVANCE FOR ALL REQUIRED INSP^{CIDERS AT 12MI o&68S =. COMPETE DRAWING AT LOWER AREA PROVIDED. sla,I,a X�L,iMML Tlna f roti -'F 5upto-nfLsoc Dna l 5 Q0 PLOT PLAN IDraw to Sw1a1 Sul. 1 . NAMES OF 6 BEETS 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 DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. { 3. 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 WALKS. - ON THE PROPERTY OR ADJOINING PROPERTY - DEPARTMENT USE ONLY Aaana.non wccrotaa BY Dale I Grout lmlNNNon BY Date Puma lmasolon BY Date I Oseruatlan Impaction B Dna - 94 Comma,H: E r ACCOUNTND ONLY: AIDS FACS PECODES FEEINFO AMOUNTREMITTED CHECKSICASH RECEI BY DATES PEIMITISEIVLCEREQUFDTNUMem INVOICE