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APPLICATION FOR WELLfPUMP PERM'' SAN JOAQUIN COUNTY PUBLIC HEALTH SEES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 (209) 46$.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (cor"plata In Triplicate) APPLICATION 15 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 i JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. �I t f Je ) ; JOB ADDRESSIOR-�AP1N.I L D LpV Y{ ,CITY 1,00 I _ �FY 1 PARCELSIZEIAPNr 7 7-7 ^��! OWNER'S NAME�JOn Y1 1 14 0M f AbbRESS�110 Od W. 14M 1 t 1 t DIA" 1, 14. PHONE r 7_ J 7^07 Y 6 co.h"11'AN1 d d �H NP rah ADDRESS Y�d3 u L C,o1lTiRACT9R `` 1�h{.l f r 1 Lt s4ch Lie/ PHONE N V 0 ��II,pp QQ 1 SUR CONTRACTOR 50; j" � S�rwi{�t ADL]REBS H 1 S rP ITT- g8Y11G1 L1c,PJrPIfONE 167 �I-I�p! I . r TYPE OF WELLMUMP: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 0 ❑ OTHER ❑'INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r e J i I New 11 RepeEr H,P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ITOF PUMP/ ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION 9PECRICATIONe - A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVAT16N. 3 DIA.OF CONDUCTOR CASING D ❑ DOMESTMIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASING/STEEilp1/C /— DIA.OF WELL CASING p 11PU8UC/mUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL : . �0,-- SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLEO'BY �.. GROUT BRAND NAME 1 4)I[4- f M MONITORINGEO I GROUT SEAL PUMPED: ❑Yes ❑No CONCRETE PEDESTAL BY DRILLER:[Ies Ya,a Ne 5, APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S l PROPOSED CONSTRUCTIONMAIWNO METHOD; MUD ROTARY AIR ROTARY AUGER_CABLE OTHER tti 1 I Hf9ESY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN 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 wow FOR WHICH ! THIS PERMIT 16 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBZONTRACTING SIGNATURE CERTIFIES f THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT SS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WaRKMAN'9 COMPENSATION LAWS OF Cloned X ADVANCE FOR ALL REOUME`D INSPECTIONStAT 1p2091 400,342x3. COMPLETE DRAWING AT LOWER AREA PROVIDED. SALTED CAlN,7T_ML�T�C'LL 2 1N A_. Title f[I��f r 514 I' Pa!O T S Date M Q V C 'Jyv PLOT PLAN IOrow to SaMe1 ScAle�w'te. 0, i 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, l 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. .:............I .,.... ......,...,............,..,., _ e .. ., 4 a C� 5 :. ..: .. . .. . . ... .. . . .. .. _ _ .. 1 -' . ............................... -. ., -,....... ;.. .:,. - ........... .. ., .. ., - - . - : :•a. �.t�.-ter-,. - �.w-rrr .1