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APPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SEMI iS ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 95201.988 (209)468.3420 NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED (Cemplett in TrlpfientE) 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 E JOAQUIN COUNTY DEVELOPMENT TITLE, i,CHAPTER 9-1115.3 AND ,THE STANDARDS OF SAN JOAQUIN COUNTY �PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DMSION. JOB ADDRESSIOR APN/ !3 f.5 WI1,L,'ftj'10 U 111 CITY � S10(- 7'al �/ PARCEL SIZE/APN/ p OWNER'SNAME - /%Cil( Oil( �V( du rf�� co ADDRESS A0.80x .�l/�a�"/�z3yyn�l_�(44W PHONEISIU�JC--K&, CONTRACTOR L4-egq IIJr1I�tY1Q ADDRESS 9VO hIV`C RZI NY/<✓)'/142uc/ PHDNE -.TIJ- I I SUB CONTRACTOR ADDRESS LICI PHONE TYPE OF WELLIPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL I ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL ❑Naw❑R p.1, H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL (TYPE OF PUMP) _ ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL I (r SOIL BORING - ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING ❑DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASING ❑PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION_ �❑r IRRIGATION/AO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAM j/ t8i MONITORING GROUT SEAL PUMPED:❑Yw [IN. CONCRETE PEDESTAL BYO R:❑Yr [IN. APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE yi PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER O `f 1 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 A 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 WHI THIS PERMIT I6 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERHF THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS CALIFORNIIAA\\/\/\A'�.��1��1',�T,,,,HE APPLICANT(MUST CALL N HOURS IN ADVANCE FOR ALL REOUMm/SIINSPECTIOON4 AT12M)4400044437.COMPLETE DRAWING AT LOWER AREA PROVIDED. pL Sio,md X�/- l� TIS. /�J. 6--e-010q a D.t. -! eP-?6 PLOT PLAN(D,—to Scat.)Spala 'to 1. NAMES OF STREETS OR ROADS NEAREST TO On 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. PAME 'T 14F lye n FFB2 � 1996 3rjN JGaGu _. . MEt r?UBLTAL HEA TH IDI4'ISION NVIRON DE►MTMENT USE ONLY l+II Application A..Wl d BY Data Tom' �( 7 Ar- -- —action BT Dat. Pump Impaction BY Data f D-VucUon Iapacti-By Data Comment.: ACCOUNTING ONLY: AIDI FAC/ PE CODES FEE INFO AMOUNT REMITTED CHEC CASH RECBVED BY DATE PERMIT/SERVICE REQUEST N111Y91 INVOICE SCJ d 1/ 2 Zrtoo �'�