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` APPLICATION FOR WELLIPUMP PERMIT • N JOAQUIN COUNTY PUBLIC HEALTH SERVICES ' ENVIRONMENTAL HEALTH DIVISION P O BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201388 (209) 4683420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in TFiplieetel PPLICATION 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 COUNTRY'MOUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. �n ROB ADDRESS/OR A��PNf# M��I / �- t Lz8-rr vVl'l r V T" CITY )^�IO�V-,V� C� PARCEL SIZE/APNN/77 ZCN_/39^--T WNER'S NAME /V Lr�' I '^ ADDRESS '✓GIVI)7' ! �- l� PHONEN �IIf��D / CONTRACTOR ( V�^/S Ef4i'J/AyE2lt1& .JJI)L- ADDRESS 'tl+G. UCN 64 9?15-;H ONE I��Y 77Cj�/U Sc ,UB CONTRACTOR Irl ADDRESS UCi PHONE N TYPE OF WEUJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL N ElINSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR VAPOR EXTRACTION WELL N J ❑New❑Repeir H.P. DEPTH%IMP SET_FT. FIRST WATER LEVEL 0 TYPE OF PUMP) `T-� 32 S 1-1OUT-OF-SERVICEWELL ❑ GEOPHYSICAL WELL Y `IeQ 601E BORING i tj DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS l /1 A INDUSTRIAL 13 OPEN BOTTOM DIA.OF WELL EXCAVATION_ DIA.OF CONDUCTOR CASING D DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEEL/PVC DIA.OF WELL CASING D PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL FlJ 11 IIY)/VVI, SPECIFICATION �A� / N ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALL 1/YI I V' GROUT BRAND NAME �� VO f tT c;7i E IMONITORING _ j[LL GROUT SEAL RUMPLED: s ❑No CONCRETE PEDESTAL BY DRILLER:❑ .�No S PPROX.DEPTH /U - /� FL L. LOCKING CHESTER BOX/STOVE PPE 'Q_ 5 PROPOSED CONSTRUCTION/DIOWNG METHOD: MUD ROTARY AIR ROTARY AUGER �� CABLE OTHER HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WTH 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF AUFORNIA.' T E APPLICANT MUST CALL U Is/I! ADVO N1/LSE�ILFOR�ALL REQUIRED IN 'fS ��P jEC DT eIONS AT IZOYI�4/N/��34{2I. �C/OA�M/�PL'ETEnDRAWING AT LOWER AREA PROVIDEED. ,Ipnetl-Y� � V V�/ Tltla I/✓1 kc I7f Y Y \'/YV' r 1.4-1` Det. / PLOT PAN (Drew to Scale) 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. 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. ��F_o7-t::c(tlj((cA-� TUR) s xC pr IlAt stf MAtiieI, Egk 4 0 Z �I DEPARTMENT USE ONLY pplicetlon Accepted By Deb Arm rout Impaction By Date Pump Irupectlon By pets astructlon Impaction By Det. ommente ACCOUNTING ONLY: A. FAC* PE CODES FEE INFO AMOUNT REMITTED CHECK*ICASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE