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APPLICATION FOR WELLIPUMP PERMITI ) SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX aft 304 EAST WEBER AVENUE, STOCKTON, CA SMI-388 (2091489-3420 op NON-REFUNOABLE PERMIT EXPIRES f YEAR FROM DATE ISSUED � 4 IComplotn In 70plints) APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAA JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS Of SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APNI �O �Q Z CITY LG PARCEL SIZE/APNI24�2/FLS' OWNER'S NAME �/I c I ! l 4- e _ o- _ADDRESS IU 4'01 /t- IV�t/� Z L y _PMONE I' CONTRACTOR t r ��!/cl C AObRE88 S��G .V. S6•C LICI 2-7;r f97 PHONE I SUB CONTRACTOR `" ADDRESS UCR PHONE/ TYPE OF WELLMVM_P• ❑ NEW WELL ❑ REPLACEMENT WELL `❑ MONITORING WELL f I OTHER ^, - ❑ INSTALLATION ❑ WELL SYSTEM REPAIR >J CIOBS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL ❑Naw❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL d (TYPE OF PUMP) ❑ OUT-OFSERVICE WELL ❑ GEOPHYSICAL WELL Y ❑ SOIL BORING g ❑DESTRUCTION' t INTENDED USE IYPE OF WELL - CONSTRUCTION SPECIFICATION{ A( ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D� DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEEI/PVC DIA.OF WELL CASINO DI i ❑ PUSLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ iRmATTONIAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yee ❑No CONCRETE PEDESTAL BY DRILLER:❑Yes ❑Ne !`'S'' APPROX.DEPTH LOCKING CHESTER SOXISTOVE PIPE S' PROPOSED CONSTRUCTIONMRILLING METHOD: 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 SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULER 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 WHICH r THIS PERMIT IS ISSUED,i SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES ,• THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT i8 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THzz AN MUST ALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT t20014"4422. COMPLETE DINAVONO AT LOWER AREA PROVIDED. .. I 6lpnad X Tit4a //�'i� //CS"z/!fes ��/'�G'� Dete�'� iAPILOT PLAN(Drew to Scale)Sgaie�_"to 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 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 PROPEIRY. „ . . .. w r t l -...., I . .. f - .. t jfu�s �a/s r } a J'fK I I -_ _ �p . ..... ...... SAN .. .. ......... ... ... PU" JtJ/t,C�ull� ( Ul«i tNVIRd� }-tEAI DEPARTMENT USE ONLY Application Accepted By Date C/ Al- C/ ' Grout Inspection By Date Pump Inspection By Date l .• DD roctien�lrapeotlon By Date v Comm t* cly- ACCOUNTING ONLY: AID# FAC#r +i I PE CODES FEE INFO AMOUNT REMITTED CHEC ##CASH RECEIVED BY DATE PERI#TTISERVICE REQUEST NUMBER INVOICE 0S so SIS 9(o &2l, l