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F x APPLICATION FOR WELLIPUMP PERMIT yr SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON. CA 9MI-388 (2091460-3420 ' NDN-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 WORK DESCRIRED,THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN_COUNTY DEVELOPMENT TITLE,CHAPTER 9-111 5.3.AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DINAMON. ..' JOB ADQRESSIOR APNI' CITU Y'11 G' PARCEL SIZFJAPNI -33-1770'73 - - - q�J OWNER'S NAME C I%pory"_ P(v 4 V<. (-ri- C�t�t 4?CL N�I ADDRESB D.Qc {�(�� Cc.cs�orl l PHONE U Py2�I-I 4F ICO (CONT+R�AyCtT`O)R I Iict►� �✓iLC-• ADDRESS q j u"Z�+c `I3 PHONE Jr b /--f ryOD l 14011 RACTOR f �!C1�Ll./)`r�-� �Lrf C. ADDRESB�I �� [".� .t/Li PHONE?"'),vu IF t c TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONrrORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑New❑Repair H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL O RYPE OF PUMP) '•�'"A.- ❑ OUT.OF•SERVICE WELL ❑ GEOPHYSICAL WELL P ❑ SOIL BORING S DESTRUCTION: !r GoN r t i?P/c� f:�i+�a r1 r'�I�n C'wJ rl� S A11 P� /'t s t ltn�t h/ta' lc�* d z I-�r°c INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS R/ .A '"❑ INDUSTRIAL 0 OPEN BOTTOM DIA.OF WELL EXCAVATION GG DIA.OF CONDUCTOR CASINO D ❑ DOMESTICIPRIVATE + GRAVEL PACK/SRE TYPE OF CASINGISTEELlF'VC�5ch. �/0 �� DIA.OF WELL CASING v o ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL .�, _ SPECIFICATION R ❑ IRRIGATION/AG ♦ �❑OTHER ! GROUT SEALINSTALLED.BY j GROUT BRAND NAME i ® MONI70RIN0 J W -D I I GROUT SEAL-PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER:❑Yr ❑No S. APPROX.DEPTH 7 LC/C l�S.__�_ 7: _ - LOCKING CHESTER SOX/STOVE PIPE S" PROPOSED CONSTRUCTIONIWVLLING METHOD: MUD ROTARY AIR ROTARY }' AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THATTIIE WORK WALL'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"SIGNA'TURE 0rIFIES THE FOLLOV43NG:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOFK-FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAMS COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THEE OF THE WONIC FOR WHICH;Y111B PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORFONAN'S COMPENSATION LAWS OF CALIFORNIA.' T AP'PIUC�ANT MUS CA 4 HOURS IN ADVANCE FOR.'ALL'REOt11Ft6D INSPECTIONe AT 1200)4".5422. COMPLETE DRAWING AT LOWER AREA PROVI ED. F Signed X `^� i7..1.' Title .� .`1V 1. e'd' PLOT PLAN (Draw to Sealel Scale_ 'to y() 1, NAMES OF STREETS 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. 2. 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. ., ... ..i.. ..'.. ..., .,- 1 Mw r ,. . .. : ....:.. .. .... .... � J3 : I ,. W7 DEPARTMENT USE ONLY A 7 . Application Accepted ByData Area Grout Inspection By Date - Pump Inspection By Oala Deatructlon Inspection By Date Col+tmenta: /y ACCOUNTING ONLY: AFOT - FACT PE CODES FEE INFO AMOUNT REMITTED C ECKI/CASH RECEIVED BY DATE' PERMITISERVICE REQUEST NUMBER INVOICE .1 K �/'7 Al Z-0'7 1 �