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APPLICATION FOR WELLIPUMP PERMIT SAN .IOAAUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988.304 EAST WEBER AVENUE. STOCKTON. CA 9241388 {209) 469.3420 NON-REFUNDABLE PERMff EXPIRES 1 YEAR FROM DATE ISSUED fit! j l. tl� IComp4b In Tripl'intil APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANgIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT ITITLE.�CHt AFTER 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLICM -HEALTH SERVICES,ENVIRONMENTAL HEALTH DSION. -JOB AODitEB&GR APPN. �o.I YV S'}�r�`� f1 �"F , CITY ( 4[`.,P['4p-fl1 -_+ - PARCEL 812ElAPTI.��__15o~3O OWNER-8 NAME ` �� '� 1ckt -r�,. ADDRESS P? Sdb( 12 p Sxl 1�pPo,,,-)-1-1—A—)-7H CONTRACTOR x n V.1� �� S ADDRESS �1 LECs�'D I D I PPHHO�E 1535-0 OdY>IRI l�-� Rl{9- �.4 5v t•e,�I 0( t� � C\915 f� SUBCONTRACTOR ADDRESS Q. �A UCI PHONE/ TYPEOF MP: ❑ NEW WELL ❑ REPLACEMENT WELL m1MONRTORONo WELL IM�AL ❑ OTHER . ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROS&GONNECT REPAIR ❑ VAPOR DMIACTION WELL 1 mJ y ❑New 13 'Rion H.P. DEPTH PUMP SET FT. .• FIRST WATER LEVEL O rrYPE OF PVMFj ❑ OUT-0F-SERVICE WELL ❑ OEOPHYSICAL WELL,f ❑ SDR.SORING. •: 8 DESTRUCTION• h NTENDED USE TYPE OF WELL CONSTRUCTION SPECIRCATIONS t IL A D INDUSTRIAL ❑OPETi;,BOTTOM DIA.OF WELL EXCAVATION `(, DIA.OF CONDUCTOR CASINO D -3 DOMESTICIPOVATE ❑GRAVEL PACIC/612E TYPE OF CASINGlSTEELJPVC vr DIA.OF WELL CABRNG 3 PUBUCIMUNICIPAL DRIVEN DEPTH OF GROUT SEAL SPECIFICATION --- tMOATIONIAG ❑OTHER ALL GROUT SEAL INSTALLED I �A OAT 1�11a GROUT BRANS NAME Q w F X-ONITORING �� GROUT SELL PUMPED')4Yw ©Ne CONCRETE PEDESTAL BY DRILLER:❑Ya+ ❑Ne IS S tPPROX.DEPTH - LOCKING CHESTER BOXISTOVE PIPE _ � S ,J ROPOSF9 CONSTRUCTIONJb14LIJNG'�METFIOD: MUD ROTARY AIR ROTARY_ AUGER CABLE OTHER- , nl jt 4 HMBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK W[LL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND EGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:7 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH HIS PERMIT IS ISSUED.1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR Sue-CONTRACTING MNATURE CERTIFIES HE FOLLOWING: •1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMFr ES ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEMSATION LAWS OF :AUFORNIA.' THE J1P MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPWTIONS AT t2041114"-2423. COMPLETE DRAW NG AT LOWER AREA PIR Vfb . k '9rw4 X_.—- .I' .. Title Det• /LOT PLAN(Draw to Sodo)SaaN 'to NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. OIMENMWD OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED 5. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.' t'_ STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPEFTY. .....:.:..............:._...:..................:.........:_.....:... .. .. .. .. .. .. .. - .. .. ..----.. ..c.. .. .. .. .. .. AAAA ..;AAAA .:...:.::... - AAAA.. AAAA ... � - � - - ._..:.....1.....:,.-...(:......:.......:......:..... .AAAA:--- . ....... ..'. AAAA. .'AAAA ... . .............:......:....,..:.....:..............'..'....:......;......c.....:... ..:... ..:.. ..t... .. .. I^ ......:....___.....,.............:...............:......:......:..............:......:......1...L..-AAAA..:. DEPARTMENT USE ONLY - �eiiastlen Aaoepted By - bat* s .,t Irry.tt{on By ,, Dote Pt p Irwomucwt B T Pau +.rnietbn Irrpoot 0 Data ,mrr.wtto: . E ACI:OUNTINa INLY: AODI PACE . r - - t r'E CODES FEE INF" AMOUNT PmwTTID LH ASH RECf3V6'D SY• DAIT P9tMIT1SERVICE REQUEST NLWAZER INVOICE 0 / 3