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APPLICATION FOR WELLIPUMP PERM'. SRN JOAQUIN COUNTY PUBLIC HEALTH S1: ES ENVIRONMENTAL HEALTH DIVISION 5 ' P,O, 8OX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 � (209) 469.3420 f+lONf•REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APPLICATION 1$HERE BY MADE TO (COMPlata In Triplicate) THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR 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 AODRESSroR APNA 6 LQY CITY O 41 ••7�.• PARCEL 812EJAPNA OWNER'S NAME IJ06%. i 6M I W. �+e'f� iew+4 L. � 331-0146— L41 . � C O hl 4 I ra NR A" ADDRESS �pU PHONE r _ POK M 141 ADDRESS 1403W- f a !! I S—.._�. MLI NG y. LION PHONE Bee CONTRACTOR50!f5 6t 4QrglI� 5-erN1ct S -- .... ADOREBS lS5y I f rt I)r- (t]P h lL i�Ct S 4;L 6 7 6 PH NEr 1 q 5--9-l/'I TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MpNITORING WELL 0 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR E%TRAC7KIN VYELL1 J RYPE OF PUMP( ❑New 11 RepaEr H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL p ❑ OUTorSERVECE WELL ❑ GEOPHYSICAL WELLN SOIL BORING = 8 T ❑DESTRUCTION: INTENDED USE TYRE OF WELL CONSTRUCTION SPECIFICATIONS ;1 1313A INDUSTRIAL OPEN BOTTOM DIA.OF WELL EXCAVATION_ l� DIA.OF CONDUCTOR CASING p ❑ DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO187EELIPVC ` DIA.OF WELL CASINO L p ❑ PUSLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL �' SPECIFICATION ❑ IRRIGATIONIAO ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME r 0II C#– f If qps� I La MONITORING I GROUT SEAL PUMPED: ❑Yee [IN. CONCRETE PEDESTAL BY DRILLER:❑Yw CRN* S APPROX.DEPTH_ 0 LOCKING CHESTER BOXMTOVE PIPE 5 II . PROPOSED CONSTRUCTIONIDRILUNQ METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER _ �9 { 1 HI EBY CERTIFY THAT 1 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. }TOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OP THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 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 PERMrT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091460-342S. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X r lAt 74,rUAlt, Tnla 51t0 fl r 5)41",f {i-#r0 j S 7,,,_ 1_1 Q Y C h IT, PLOT PLAN IDraw to Seale)Seats_'to L10 !� 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 PROPERTY. c i I ..a C f D ., h :. .,.., ..,..,..... ............ .....,. .... . l . .,. . : . .. ........i.. .. . ....,..., . ...... . I a } . :' t DEPARTMENT USE ONLY Application Accepted By Date 3 'it� a' Area Grout Impaction By Date Pump Inspection By .L DNe bestruetlen Irkepeetlon By - ." (�,,,� �� •;,}� /'� ,/�� Date /f �J' Comments: vol P1 rE0 S a55 QF In.L6-KTh I IC Y 1 f C'_�5 Q� lal9 Lr r ACCOUNTING ONLY: AID/ FAC/ �t i PE CODES FEE INFO AMOUNT REMITTED CHECK/!CASH RECEIVED BY DATE POWI�TISERVICE REQUEST NUMBER INVOICE MftAL`-io TR Il