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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICEl ENVIRONMENTAL HEALTH DIVISION WSW P 0 BOX 388,446 N.SAN JOAQUIN ST.,STOCKTON,CA 96201.388 (209)468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (GKykn M TIIPIkEnI �...• 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 8-11115.33 AND ♦THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH DIVISION. 2�-I qd-I` JOB AGGRESSION APNi-./l0/11�W t I/''+-` S(1/r,`� CT' `'� �\ PARCEL 'SSR/'E/APN*-,?.3�•CrT'��-q�•��/•l R� OWNER'S NAME Dr. t-, 9, I-LI v- c ADDRESS �C�• �I G 'THAI- CIA-qQ I ,,..i 4 O-�J /-;I0c)� .� CONTRACTOR •T"' YL VFVY\.VHM'�ti�"P I ADDRESS «7 T�OMAI,�3j-� '.1�1`y�,,, On moi(A�IIIIc'/`]) .!2 a 1 F-3 `0)� SUB CONTRACTOfl_— ADDRESS Z^LS UNt^".^ t LAr-��f PHONEI 46VI ��,��TTTF Z2�erlL'L,~�'T/�4.tT/ik TYPE OF WELIA'UMP:)g NEW WELL ❑REPLACEMENT WELL MONITORING WELL I--L,21,3 ❑OTHER INSTALLATION ❑WELL SYSTEM REPAIR ❑GOSSCONNECT REPAIR ❑VAPOR EXTRACTION WELL i J tIPPI ❑N-❑Pe.b H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL O (TYPE OF PUMP ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL i ❑ SOIL BORNO S ❑DESTRUCTION: .I INTENDED USE TYPE WELL CONSTRUCTION SPECIFICATIONS q ❑NDIISTRIAL ❑OPEN BOTTOM ------yyyyyy��111111��I��I��-��- ��.��. DIA.OF WELL EXCAVATION /1 DIA.OF CONDUCTOR CASINO 1^ O 13DOMESTICA'RIVATE 'gGRAVEL PACKISIZE TYPE OF CASINGISTEELJPVC ^ DIA.OF WELL CASING_ ^t�2Y` D ❑PUBLIC/MUNICIPAL ❑DRIVEN 2 t k/ DEPTH OF GROUT SEAL c L.l" SPECIFICATION l,h. R ❑NWt1ATION/AG ❑OTHER GROUT SEAL INSTALLED B S CO-- GRDUr BRAND NAME E SEAL PUM MSR APPROX. PROPOSED DEPTH 111CTIONAIRIWNG METHOD:MUD ROTARY GROUT RG AIR ROTARY PED:�YM ❑ISTD LABIE CONCRETE PEDESTAL BY�DRIIJ�FR:❑YM NO S APPIIOX.DF1fN �7 1'�� LOCKING CHESTER BOX/STOVE PPEl •QV'E) GER 1 HEREBY CERTIY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE N ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATION B OF THE SAN JOAQUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:21 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN%COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUBCONTRACTRIG SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN-4 COMPENSATION LAWS OF CALIFORNIA.' IIST M i CALL M IDU%N ADVANCE FOR ALL REQUIREDINSPECTIO`N'S AT 12051 SSE-1/37.COMPLETE DRAWING AT(OWER AREA BONDED. a15,•.e x � `1. TIa. `2>_T �0•L-c i R-.r o.t. 4�D -Z Cl —I PLOT MN RX-1.SUI.)SUN 1.NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING 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 WE ONLY ApPN-Ion AUyt.M BY D.0 N.. a—INP..tl.n BY Dat. Pump Imp-Ilm BY D.t. D. -,I.n k pWl.n BY tw C-- ACCOUNTING ONLY: AOI FACT PE CODES FEE INFO AMOUNT REMITTED CHECKOMASH RECEIVED SY DATE PERMIT/SERVICE REQUEST NUM89t INVOICE MAS