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APPLICATION FOR WELLIPUMP PERMIT ) '*, -SAN JOAQUIN COUNTY PUBLIC HEALTH SERVie.-; ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STObKTON,'CA 95201388 (209) 468.3420 n NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROG DXtE ISSUED (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR 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 COUNTY PUBLIC HEALTHY SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN# T '�,J` VrV f'°�tTGrQ\4.{Jpf� 1��+� + ['- CITY D'1�,1g��T/CJ IqV �+w PARCELL SIZE/APNI OWNER'S NAME /EQU`1-VtQ r-��V TE+`.P�O SEE S `�'� ADDRESS F0- p 60+�y QAR'�1D�/Q 1.A 9��I"7 PHONE 1��9��^.��1 CONTRACTOR L�Fliv\�7B�P�,V"� Gr�p+�(�»1"�GyTPCL ADDRESS P•0 Ek),V-269,,p�� O1-A 1 LICA' /iG {{f�� PHONE 1 6 -449 SUBCONTRACTOR G�� f►tt_LIN� - ADDRESS RW �{UY�i✓�_ ~T11166 LICK 495165 PHONE#42 3113'{.,*0B TYPE OF WELLMUMP: NEW WELL ❑ REPLACEMENT WELL LiQ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL U (TYPE OF PUMP( ❑,OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS C� A ❑ INDUSTRIAL 1110�EN BOTTOM DIA.OF WELL EXCAVATION ti DIA.OF CONDUCTOR CASING D 11 /P DOMESTICRIVATE 9 GRAVEL PACK/SIZE fir'Z 1!%' TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING �7 D 11 -T PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION EC41 MJ R ❑�/JRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY (a r; 1Er- GROUT BRAND NAME �,/ E In MONITORING GROUT SEAL PUMPED: ❑Yes ❑No CONCRETE PEDESTAL BY DRILLER:LrJ Yw ❑No S APPROX.DEPTH �A/ LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL 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 SIGNATURE CERTIFIES THE FOLLOWING:'1 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 SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF-THE WORK-FOR WHICH THIS PERMIT IS ISSUED,.I-SHALL EMPLOY PERSONS SUBJECT TO WORKMAN's COMPENSATION LAWS OF CALIFORNIA.*STHE APPUC T 6T CALL 24,HOURB IN ADVANCE FOR ALL REQUIRED INSPECTIONS��A12091480-3423. COMPLETE DRAWING AT LOWER Date A:AREA PROVIDED. Q � �� Title Ci/ [J IF PLOT PLAN (Draw to Scaler Scale 'to � 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. 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. f r ... .. .................................................................a......:.............:.............................:.... DEPARTMENT USE ONLY �N � (( Application Accepted By L Date (/ / Iq C1 res ,3 / V"D Grout Inspection By / 4 1 Pump Inspection By Date Destructlon Inspection By Date Comments: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECRVIED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 3501 AN � -