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a I 7 APPLICATION FOR WELLJPUMP PERMIT SAN JOAQUIN ICOUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION . 304 EAST WEBER AVENUE; STOCKTON, CA 95202 (209) 4683420 1 It NON•REFUNDARE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complata M:TFIpReatel APPLICATION 19 HERE BY MADE TO THE CAN JOAGUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DE9CRIBED.THIS APPLICATION t8 MADE IN COMPLIANCE WIIIt SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 13-1 1 16.3 AND THE BTANOARDS OF BAN JOAQUIN COUNTY PUBLIC IIEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AObRE991OR APNJ t l f� .I :^I�L�C .CITY_T, 1 �. v _ PARCEL SIZFJAPNP OWNER'S HAMS r� ------ ,ADDREee /111"1 -1 rr �.n fr.• MSONE I'1 ! f_��C'�..f /1717 CONTRACTOR f7 17-';I ! r r•'C I r'Inc'c_. - - - ADMSe SUBCONTRACTOR :;Ir'C !"1;/"/'I y.f)Ir 1-1'4I1 1', _ ADOitE es �'[ /i�l/t 1, nroJ-�;1,4 LIc1Y-��7_.1721,5 P41oNE'L, I E' TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL E .ONITORINO WELL/ © OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR" ❑ CIROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL 9 J ❑New❑Rapelr H.P. .: :f` OEPTFI PUMPrBET FT. FIRST WATER LEVEL O RYPE OF PUMP) ', ❑ OUT-OF-SERVICE WELL' ❑ OEOFIIYSICAL WELL R El Bell.BORING 8 VO-0 Ilk 1)v n f 10 DESTRUCTION- 1-�f'+/L,': 'i /J�.fl/}. f -'�.'{; ,/ L.l i� �`_1=Lj_� - L�_btn ;I,ir•. ��5yt•y�' f Idl-7rn Il'I?-`rr. INTENDED USE IYPE OF WELL ., CONSTRUCTION SPECIFICATIONS _..'C C 11 INDUSTRIAL 11OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO f D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELIPVC DIA.OF WELL CASINO O ❑ Pui3m MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION A ❑ IIBgGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROW BRAND NAME E ❑ MOMTORING GROUT SEAL PUMPED: ❑Y. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑YM ❑Ne S fffAPPROX,DEPTH LOCKING CHESTER BOXISTOVE PIPE S OSED CONSTRUCTIONRIISLLING METHOD: MUD ROTARY AIR ROTARY : D AUGER _CABLE OTHER 1 HMBY CERTIFY THAT T HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE M ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULED AND REGULATIONS OF THE SAN JOAOUITI COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE;CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE Of THE WORK FOR WHICH THIS PERMIT IB ISSUED,I SIIALL NOT EMPLOY PERSON$SUBJECT TO WORKMAN'S'COMPtNSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRINO OR BU"ONTRACTINO SIGNATURE CERTfFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 19 ISSUED.I SHALL EMPLOY PERSONS BUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS tN ADVANCE FOR ALL RIMMED INSPECTIONS AT(2001 4"447]. COMPLETE DRAWING AT LOWER AREA PROVIDED. _ -t Btaned k^ / `�.!i ,d`�1J7`I:2,r,;1.• TIIIe :.a- r•l_J".Cr ._� 1 f/}'� .I/ Dete 1 ( - - PLOT PLAN Mk—to Social Seale 'to '- 1. NAMES OF STREETS OR ROADS NEAREBT TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 7. OUTLINE OF THE PFIOPERTY,OIVMIO DIMENSIONS AND NORTH DIRECTION.- EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLIPIF.S AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WMIIN PIAMO OF ONE HUNDRED FIFTY FT. STRMTUMB.MICLUDING COVERED AREAS SUCH At PATIOS.DRIVEWAYS.AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. r — • ''►ems :`l' -.ee�'.a`�r-._ .re--_ �... ..I�._✓..- ,ar�•`.c,....-�"..`c.,.,"4 _'�_ - �. � .�f � �r.�-+;�..=...�..:`SiF Imo?' ..,. ...... .. ...... ......,..... ........ .,....... .-. !1 7 .'4EPMTMENT;USE ONLY Application Aeeepled By .� -I 4 I f !! Dot■ AVN v •F Groat Irrpeetbn By Dau Pump Inrpealten BY Dela Deunwtlen Impeellon BY ' Oet■ C amm"I'M ACCOUNTING ONLY: AID! FACT i} PE COPES FEE INFO AMOUNT REMITTED CIIE[KfICASH RECEIVED BY DATE p8iM1T1SFAVICt REQUEST NUMBER INVOICE