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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicatel APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/Oft 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 HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. o JOB ADDRESS/OR APNJ11 I�,^L r cITY '\L.t�T/) l� PARCEL SIZE/APNI_5_rJ, OWNER'S NAME u I VI LII �C4 VI-t ADDRESS F_ RHONE 1-5711-- I 1 CONTRACTOR 1).7q,.(, II1ADDRESS I1 1 HI ✓'\ I�'In TIO I'}(AC#4;s, PHONER SUB CONTRACTOR ADDRESS UCR PHONE I TYPE OF WELLIPUMP: ❑NEW WELL OREPI.CEMENT WELL ❑MONITORING WELL/ ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS CONNECT REPAIR ❑VAPOR EXTRACTION WELL i ✓ ❑New❑Popelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) ❑OUT-0F-SERVICE WELL ❑GEOPHYSICAL WELL• ❑ SOIL BORING @ 4 � DESTRUCTION: I-_J t L((✓l c, L�r�A/l I:o40-- -r! INTENDED VSE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A �yL❑�I INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION /.f DIA.OF CONDUCTOR CASING D LLY DOMESTIC/PRIVATE jZGRAVEL PACKUSIZE TYPE OF CASING/STEEL/PVC Int DIA.OF WELL CASING Y D ❑PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL .Z ��.J� SPECIFICATION / R ❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED By'/)�'/�J�.. 1 IT' GROUT BRAND NAME Li�/�I—. E ❑ MONITORING GROUT SEAL PUMPED: C_Y— ❑No CONCRETE PEDESTAL BV DRILLER:❑Yr 0-Ho S APPROX.DEPTH TCJ/L/ r�K�7 / LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY��AIR ROTARY AUGER GABLE OTHER 1 HE9EBY 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICHC THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIESC THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS O CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1209)4"3423, COMPLETE DRAWING AT LOWER AREA PROVIDED. Slerwd X OL... IA4,x,2t .LI TRI. � !I��f De ,,--�'— PLOT PIAN(Drew to SoNel SuIe 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 OUTUNFS 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. PAYMENT Sys E VD .. ;..... MAR Z 4 1995 AN JOAQUIN UC)UN FY FUOLICHEAMA.SFRVICES ENV(-RON'MENTIAL.E(EWT`I DRV"..Rif; I �C7� Fe s t (qv, yT� — ( 01 `J� 7777777777777 \v� ......... IS 8�f 0 LgY' I' _ DEPARTMENT USE ONLY Application Accepted BY DNa 7. S Ara 7 l— 1 Grout I—pection By z Det Pump In Pe tw,BY Deta Dwt,m6o,,Irnpecti/on By CommenlL:��✓ D ACCOUNTING ONLY: AID( FACN PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECOVED ELY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE k' ) za, 5_;`3 o �� , - 5s SO