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APPLICATION FOR WELLIPUMP PERMIT NwAN JOAQUIN COUNTY PUBLIC HEALTH SERVIN4W ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, ., STOCKTON, CA 95201-388 l- 3� I�Ickb�$-t, (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) I APPLICATION 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 COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN# S7Cf-*hU. CEI l 7�C-SR 141)t�r.IPa-•P D CITY -Smck-Tv� GPs PARCEL SIZE/APN/ OWNER'S NAME r� �v�6. C Q eA T. oREss 43'Fp YOn p V�. N p A CIS*1 1 y 2--Cj,'!,�jI�- CONTRACTOR 4 W6L.1� ADDRESS 1•�•Qi] S� F-10VIirrAf-A uci -I O PHONE 47D_i-7j1�Z+OL7 SUB CONTRACTOR ADDRESS LIC# PHONE# TYPE OF WELLIPLIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J (TYPE OF PUMP) ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ,{1 t ❑ OUT-OF-SERVICE WELL ct ❑ GEOPHYSICAL WELL# ❑ SOIL BORING 7, ®DESTRUCTION: ✓ I` W$6 ��i,�y() %bI SU(zvALE M IIAtFeagTk-Tig,id726M,60 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS�y A 1:1 INDUSTRIAL [3 OPEN BOTTOM DIA.OF WELL EXCAVATION D•`LS jr DIA.OF CONDUCTOR PAIPING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/sTEEL/PVG5C44 40 P-V'C DIA.OF WELL CASIN 27.L1' --e- f9 Aa6 ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL O— ^� SPECIFICATION R 13IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME N GNT C�ICh!1 F ❑ MONITORING GROUT SEAL PUMPED: ❑Ys ❑No CONCRETE PEDESTAL BY DRILLER:❑Ys 13N. S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUICTIONIDRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE4ESY 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 WORK FOR WHICH THIS PERMIT IS ISSUED,I 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 PERMIT 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(209)4!83423. COMPLETE DRAWING AT LOWER AREA PROVIDED. III-,1'110- .G of V*W DlZI1- %N If- �+ q r ]/ Signed-X rIICJv�.W�� V .11. Title_._ _ C,6-0 r-6Q ISI DoLe 1 J ZZ CI Ip RIC IAAK►1 L..-Mv4Sor l PLOT PLAN(Draw to ScOal Scala 'to 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. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED B. 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'Zsh rm . llO = f 9•c --Zut.rD LieVet... 73 X3. 1 y x z e 2f F1;♦'f"�'R�Ac..� .. . - � _.....Conc.2>�cl� . . �.H>"I-1 .. _ .. r _ � 3W A r; 1Pirr+n I ID ... .. .a . 1 }.0.3 se,: 4t) 1696, VnIUME per_ 1#7r ,1:510x' 1.1Co.083 .I� FP•` � 11 X SI FTLI: 19' : - DEPARTMENT USE ONLY Application Accepted By Date Area Grout Inspection ey Date Pump Inspection By Date Destruction Inspection By Date Comments: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED C RECEIVED BY DATE PEAMITISERVICE REQUEST NUMBER: INVOICE