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� APPLICATION FOR WELLIPUMP PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SERV ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOADUIN ST., STOCKTON, CA 96201388 (2091468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPUCATION IS MADE IN COMPLIANCE MH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PPU/B�LIIC'H�EaA�,L�THI SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB �,{^ JOB ADDRESS/OR APNN 4'33 �• �-tZ£EV1itIJr CITY 5IVCk-1VI`r C� PARCEL SIZE/APNN Al� -?ao-39 OWNER'S NAME AjC� LTC-I/ ''aa --ADDRESS � I�II�7"-Urr[i� ✓� (( `, PHONE N �/I']/�f� CONTRACTOR IGrC7 Cf4tlI uL t 21 NL JJ L)C_ ADDRESS �IfL UCN &q7 ?ice PHONE N7"Y /75V0 SZ SUB CONTRACTOR /\/IA- ADDRESS UCN PHONE 0 TYPE OF WELVPL/MP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL N (. J ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ElCROSS-CONNECTREPAIR L1 VAPOR EXTRACTION WELL N J ❑New❑Reeelr N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O !TYPE OF PUMP) `11I.. / OUT-OF-SERVICE WELL 11 GEOPHYSICAL WELL/ `ItQ SOIL SORING �� B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS I /I —_ A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PV�C DIA.OF WELL CASING D E ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 11 l IIPI/UA- SPECIFICATION / -n R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTA D BV 1/✓-I(I GROUT BRAND NAME (26 vo f IL/I r f�/r E ❑ MONITORING /'� f-_ G GROUT SEAL PUMPED es 11 No CONCRETE PEDESTAL BY DRILLER:❑ s�No S APPROX.DEPTH /V - / J L � LOCKING CHESTER BOX/STOVE PIPE_NV S PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 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 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 IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTMCTING SIGNATURE CERTIFIES THE FOLLOWING -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' TIE APPLICANT MUS CALLU UI�ADVAN�R ALL REGLARED INy/SPPPWT•IONS AT 11208)'(S�S/a^'3,0g2.G.�COgM�PIETE�DRAWING AT LOWER AREA PROVIDED. SIP WYWV�iI'T!, ,V�/�J`I Title //L�1V/C Ii Y V l/'�/VV' L 1.'�t l`— Deta _Z Title PLOT PLAN IDrw to S a)Scale--L- 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUNE 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 AREASp SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. 67xCrrti�_SE rnA�i�4 Lt _A