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APPLICATION FOR WELLIPUMP PERMIT ;AN JOAQUIN COUNTY PUBLIC HEALTH SERV: j ENVIRONMENTAL HEALTH DIVISION P,O,BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201368 (209)468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE 138110 (Complete In Trip6Eats) APPLICATION IS HERE BY MADE TO THE SAN JOAOUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-11115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOB ADDRESSOR APN, 4 Z 31.5 Na �[/.�f�! 6 577 CT' J Q�.I/[(�JV ,( ) PARCEL SIZE/APN/APA) 1 PZ ~/Cb-/7 OWNER'S NAMEE54e ki he)I VL7 le I1,i ADDRESS G�.7��Y f'iJ1G' /JJ(,d'G S'7[X..�!'/Yt PHONE, 4-77—347( CONTRACTOR Sn 4 fr2a J1'7 �_ IQ/6"a?Liv, ADDRESS 236.5((_)��, yz,�j'kxxan UC,J/l 24>afi PHONE,'k6--8712- SUB 71.2- SUB CONTRACTOR Icy ADDRESS LIC, PHONE, TYPE OF WEU/PUMP: ❑NEW WELL ❑REPLACEMENT WELL lil MONITORING WELL, ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL, J ❑Non❑R.p.1, H.P. DEPTH RUMP SET Fr. FIRST WATER LEVEL O (TYPE OF PUMP) ❑OUT-0F-SERVICE WELL ❑GEOPHYSICAL WELL I (� SOIL BORING I B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION, A II❑pp INDUSTRIAL �❑rqOPEN BOTTOM DIA.OF WELL EXCAVATION to 0 DIA.OF CONDUCTOR CASING nn e D IW DOMESTIC/PRIVAM IRGRAVEL PACK/SIZE '12'I2- TYPE OF CASING/STEEUPVC Flo e- DIA.OF WELL CASINO 14Z D ❑PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL c SPECIFICATION •,"f ¢0 R r❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY<`1V4rDG_h'•! GROUT BRAND NAME uON. _ E y MONITORING GROUT SEAL PIMPED:®YM ❑N. CONCRETE PEDESTAL BY DRILLER:❑Y» WN. S 1 APPROX.DEPTHS LOCKING CHESTER BOX/STOVE RPE L� g PROPOSED CONSTRUCTIOWDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER IHEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN 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 16 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA."CONTRACTOR'S HIRING OR(HUS-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERT FY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT 16 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'/NTH.APP1C IT MUT CA 24 HOURS IN ADVANCE FOR ALL REOURED INrTIOMS 4441-S422. P AT 1200)4E22.COMPLETE DRAWING AT LOWER AREA PROVIDED. 610-d X N TIt1. ""l'�,�'/Li A•� D.t.LaI3n�/�f%G PLOT RAN(Dr—to SoW.)S"Is "to 1.NAMES STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISP08AL 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 R. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ..A„ PROP9TTY LEE.._ �:.�` t 9L.1 II O.1 O' Soo IST• ) 0*'B (D SB-4 RING WELLS LCN-, i..... _..'. 9.10.84• ASTE OL TALK tR9ADV®). .. HW-3 EL.10.64! �a ly SHOP t (p . rj .. E.....'. firI S.a.it, 1 2315 NO.ELDORADO Y� . ss-I-Ciea.,H.30' I ... ss-2-01eo 4.l c24' ' 0 Cle4ndo.3O- - ------ l SUCIC-4. 31* /go)-1-dean ah—7.- SCA I AIV, Ucan alasf z f l O' l 1 P. RAIU-3.Oca.ebAt 1 O 10 'D' OFFICE SUILDM DEPARTMENT USE ONLY Applie.tlon Accopted By�� D.t. ILL I[ W Ar.. G,.ut 1-wtlon BY D.t. Pump In p.atlon BY D.t. {I i Ostructlon Impaction By D.t. Comments ( ACCOUNTING ONLY: AID, FAC/ PE CODES FEE INFO AMOUNT REMITTED CH !CASH RECEIVED BY ..T& PEIVAT/SERVICE REQUEST NUMDE R INVOICE 1(Q �1GaQ95