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APPLICATION FOR WELLIPUMP PERM' ` SAN JOAQUIN COUNTY PUBLIC HEALTH SEn-wCES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (209) 468-3420 NONREFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSUED (Complete in Triplicate) 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 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# % 7 3c ��✓• -CJy1'l.Z�I-{n-✓'1� —CITY C` o Al, \ A I- PARCEL SIZE/APN# (J �7 OWNER'S NAMESI� 'G-/V l C.�lJC. �/q /V C A/C- ADDRESS_1 J`2 3 il I Lit,/1/�'/�' tL� .CO j/ PHONE X.�C+7"(J/) CONTRACTOR I.) L/-/1 (�i_✓�Y� 7 �CJ ADDRESSc,7�G - � L��/ :-S/ .5��/VLICN I L,-J.-3 J •� PHONE N �,16 SUB CONTRACTORG Gt. ADDRESS'/[�( V-((9 C/� t.IC PHONE X ?2 Z- TYPE OF WELUPUM P: l[ErNEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER 2-INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL�_ ✓ Sll LJ New❑Repelr H.P. -'1 DEPTH PUMP SET 97YFT. FIRST WATER LEVEL �4 O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS / A ❑ INDUSTRIAL �❑OPEN BOTTOM DIA.OF WELL EXCAVATION /_ I'/7 J/ DIA.OF CONDUCTOR CASING D ElDOMESTIC/PRIVATE L'7 GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC V DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ��y 2^ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY V / L I_ /' GROUT BRAND NAME R-E—TO Ni ��f f t' ' El MONITORING GROUT SEAL PUMPED: ❑Yes ❑No CONCRETE PEDESTAL BY DRILLER:❑Yea L.J No S APPROX. DEPTH / / LOCKING CHESTER BOX/STOVE PIPE g R PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY LAIR ROTARY AUGER CABLE OTHER r71 I HEREBY 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 JO QUIN COUNTY. HOME OWNER O LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISS D,I SHA NOT EMPLOY PERSO S SUBJ O WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWIN "I C RTIFY T IN TH RF Ar.A /AN'C E H THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' /! UC U61 C 24 FOR ALL REQUIRED INSPECTIONS AT(209)468-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. y Signed X e_ //��/✓ Date PLOT PLAN (Draw to Scale)Scale "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. J. 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. I ' 4 , �7% ... ....... .. . . .. ......: ........... `:' A i�R 11 1999 _ _... .... Lh r. iVl/I)il�(\ftldt R SAL iw �l 1!:1 DEPARTMENT USE ONLY C� Application Accepted Byy / t . Area 1 L Z Grout Inspection By 'i✓ ,- s..�c..� Date t y Iu Pump Inspection By (,- i-(,r-/.; Date Destruction Inspection By Date Comments: ACCOUNTING ONLY: / -�-� AID# FAC# I PE CODES FQE INPO AMOUNT REMITTED CHEC K/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE �nonI AAA I 20 - 5 2