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APPLICATION FOR WELLIPUMP PERMIT u ~SAN JOAQUIN COUNTY PUBLIC HEALTH SERVhWS ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN 209)JOAauiN 408 ST STOCKTON, CA 9620138 FCD 'Nt (209) 499.3420 NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED ICompieu In Trfpkate) APPLICATION 18 HERE BY MAD/EE TO IN COUNTY DEVELOPMENT THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SEAN JOAJOB�ADDREeBADR APNI^��y [IT'S✓. AIMLE,CHAPrER!W1,0, AND THE STANDARDS OF SAN JOAQUIN ^PUBLIC HEALTH SERVICES.ENVIRONMENTAL HEALTH WAAPARCEL eRE/APN� r7E•K/IV[/G/ OWNER'S NAME Lar J F-6 �AODREM_J q~_ j1 ao .�y^ PHONE M 17 CONTRACTOR C �. nl[ F ET ADDRESS �Lu ' ` ` f(/ UCi371� PHONE" - SUB COMPACTOR ADDRESS UCi PHONE TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL♦ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL N J ❑N.❑Repdr H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL 0 TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ SOIL WRING B I❑ DESTRUCTION, r L f INTENDED/BTRIAL )C 3 I ❑OPEN BOTTOM DIA.OF WELL EXCAVATION IONS �� O I A .�u 2 tr [�/��/ '� DIA.OF CONDUCTOR CASING O ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/BIZE TYPE OF CASING/STEEL/PVC J �l'l- DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL [3 DRIVEN DEPTH OF GROUT SEAL ) SPECIFICATION >�� y�'[+ N ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY C c.A n GROUT BRAND NAME W t 3 IfrL••R-R��l E L ❑ MONITORING �f//�( GROUT SEAL PUMPED: Yr ❑Ne CONCRETE PEDESTAL BY DRILLER:MN4 ❑N. S APPROX.DEPTH LN V LOCKING CHESTER SOX/STOVE RPE S PROPOSED CONSTRUCTIONIDNWNO MET40W MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK 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 WOW FOR WHICH THIS PERMIT IS ISSUED,I SHA EMP}}}}gQQQY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES CALIFORNIA.- THE ALIF X OWING:.'I CERT��FFFYYY��L HA N T. PERFORMANCE OF THE MR FOR WHICH T��PERMIT 16 ISSUED, ��6ON6 SUBJECT TO WODRI(MA�C�COMPENSATION LAyJ�F LMIFORNI /A'Y✓ '/]II f�1N( U C LL HO BIN ADVANCE FOR ALL REQUNR�7r�1 ECTION�•/"Lt L/3411" O E DRAWING AT LOWER AREA VI DT (// � JI MAT PLAN(DI.w to Sul.)S 1. "to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM R PROPOSED ]. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPM61ON OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. 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. ►' V, I) A'A S 00cae ! i u( ` DEPARTM&_USE ONLY Appll WN Aoaa By' n 1 fw '�-� D.. � " ' p �.�� 5� l Grout ImPWIon BY N v�Z� --�� Dots ✓`3 5 Pump IMpW IM BY D.t. DmtrucUen IMpwtion By D.t. 5 n. , R17 Cemmrm: L.V• � `- p C' k- b Q �( /✓✓J S ACCOUNTING ONLY: I AIDS FACT 1, PE CODES FEE INFO AMOUNT REMITTED CHEC /CASH RECEIVED BY DATE POWIM ERVICE REQUEST NUMBER INVOICE 13 S 3