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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388,446 N.SAN JOAOUIN ST.,STOCKTON,CA 96201-388 12091468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MomplEh in TriplkatUl APPLICATION 16 FERE BY MADE TO THE SAN JOAOUN COUNTY FOR A PERMIT TO CONSTRUCT ANDIDR INSTALL THE WORN 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 HEALTH SERVICES.ENVIRONMENTAL HEALTH"SION. JOB ADDMBSMR APNO 7735 S. RT 99 WEST FRONTAGE RD' STQCKTON PARCEL SIZFJAPN' OWNER'S NAME DAVID RAKOVICH ADDRESS 5220 N ASHLEY ST0CLU AGDNE1 952-3129 CONTRACTOR H E N N I N G S R R 0 S QRII LING CO- AnpRE66 3525 PELANDALE[I 0�2 4081?MONE0 545-1185 SUB CONTRACTORryI,AI ' ADDRESS __ UCI mow TYPE OF WELUPUMP: Id NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL I ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CnOS.CONNECT REPAIR ❑VAPOR EXTRACTION WELL I ✓ ❑New❑RaPAI. H.P. DEPTH PUMP SET—_ET. FIRST WATER LEVEL 0 (TYPE OF P11MP1 ❑OUT-OF-SERVK:E WELL ❑GEOPHYSICAL WELL! ❑ SOIL BORING B ❑DESTRUCTIONS CONSTRUCTION SPEGFWATIONS A INTENp®LIGE TYPE OF W Fy (L ❑INDUSTRIAL p❑p77 OPEN BOTTOM A.OF WELL EXCAVATION 2/0 D DIA.OF CONDUCTOR CASING D ` 11DOME$TICmRIVATE W GRAVEL PACKISIZE TYPE OF CASINGKTEEL'PVC P V l _ DIA.OF WELL CASING 1 O 11 D ❑�PUUXMUNICIPAL ❑DRtvEN DEPTH OF GFoLrr SEAL 1 O BOJ I I,I(`(- SPECIFICATION R ENTON T I F R F_ IRFWATION/AG ❑OTHER GROUT SEAL INSTALLEDI-BTY tTHq E N N I N G$ GROUT BRAND NAME py-TI E �� ❑ MONITORING GROUT 6FAL PUMPED:LJY- IN No CONCRETE PEDESTAL BY DRILLFR:❑Y- KIN- S APPROX.DOTH 3C LOCKING CHESTER ROXISTOVE PPE s Pr10POSED CONAT14UCRONIMWNG METHOD:MUD ROTARY X AR ROTARY AUGER CABLE OTHER I IEREBY CERTIFY THAT HAVE PREPARED THIS AFPUCATKIN AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORE NANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAOUIN COUNTY.HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLD. NG:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECTTO WORKMAN'S COMPENSAM.LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR BUBCOMMCTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT N THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS BU6IECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORN`IA`- THE APp11CANT.MWT CALL K MUMS IN ADVANCE FOR ALL REQUIRED INSPECTIONS 1ATI Ia�OSI oMed i.COMPLETE DRAWING AY LOWER AREA PROVIDED. � �(f""�-� D.L. P-1AY 11 , 1995 FLAT PLAN IDr+to--1�'[e 1.NAMES OF MPEETS ORROADS NEAREST TO OR ROUNDING THE PROPERTY. !.LOCATION OF HOUSE SEW ADE DISPOSAL SYSTEM OR PROPOSED2.0UTUNE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION 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. STRUCTURE6.INCLUDNG COVERED AREAS SUCH AS PATIOS,OWVEWAYS,AND WALKS. ON THE PF DPEftI'Y OR ADJOINING PROPERTY. { F } � i I In '4 _ F- Ilk I I A 1 �QI j ¢ . 4 m .... m ;.o�_ ell m 4 6 T I •- Q It, vl LU ..ti, ;.•.I Ln ..... f. IDEPARTINIENT USE ONLY . I L �_— Applicebm.-Accope By - - - _p«e - Are. (OroIA MpecLpo By Daei'y[ P lrspenlpn ar De D.vw m�pJe .By U.le Cpmrt»nuWi{O - AccouNnnQ QNLr Alw FACS PIE Co.. Ffi NFO AMOUNT FiErIRTED ...,CAS. ISCBVED BY DATE P6M1T1 W!gUEST UMB9 INVOICE 000 01