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f APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST, STOCKTON, CA 952UI 388 (209) 468 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 APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE CHAPTER 8 1 11 5 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION I JOB ADDRESSIOR APNN,z 1+?45 11M 7-H /C� �1y CITY 7. qV OWNER 6 NAME x.11 Y/?,15y�/ �� '.O7_:'0 4' S Er7��✓�ADORESS a C?dY ,�D c.�' �.&',y"A// ��jjPHHON S�� ¢�-�d g: CONTRACTOR , Y, E !iF_rA 0 .1rr 3It/ ADDRESS lfr9 reel Q�{f0�'p ucx,' "24?5'PHONs >�' V-77Zc ADDRESS � I �- /yi'�LICx PHONE* TYPE OF WELUMIMP © NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 1 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS•CONNECT REPAIR ❑ VAPOR EXTRACTION WELL x (TYPE OF PUMP) EVEL 13 Now[3RepairH P DEPTH PUMP SET FT FIRST WATER L 0 ❑ OUT-0F-SERVICE WELL' �1 ❑ EGEOPHYS4ICA,}WELL x rf F Lit".+�� ❑ SOIL BORINO STRUCTION �WJ'/ /r[L .I, y INT ENOEO USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM DtA OF WELL EXCAVATION DIA OF CONDUCTOR CASING D ❑ DOMESTICfPRIVATE ❑GRAVEL PACK/SQE TYPE OF CASINGISTEEL/PVC DIA OF WELL CASING I _D ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION + `rL1ll ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E r ❑ MONITORING GROUT SEAL PUMPED [3y. ❑No CONCRETE PEDESTAL BY DAI LPR ❑Ye. ❑No S II APPROX DEPTH I LOCKING CHESTER BOXISFOVE PIPE S PROPOSED CONSTRUCTIONIMULING METHOD MUD ROTARY AIR ROTARY AUGER CABLE OTHER J i HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOFK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES STATE LAWS AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY HOMEOWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT is ISSUED I SHALL NOT EMPLO RSONS SUBJECT TO WORKMAN 6 COMPENSATION LAWS OF CALIFORNIA CONTRACTOR 6 HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING r I CERTIFY THAT IN TPf PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN S COMPENSATION LAWS OF CALIFORNIA IE WIIZ,�NT MU)IT C]/U 24 HOO"}I,R8 IlMDVANCE FOR ALL REQUIRED IN ECT10N5 AT(209 4e0J423 COMPLETE DRAWING AT LOWER AREA PROVIDE-D1 � Signed Xf I�ri i f l Ci G'S-4.,.....�, Title / f IIID €-y.f r rr r� f � a y Dae PLOT PLAN Wrew to Solei$cala 1 NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY —r"bT 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 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 1 dh4'etc Oxo 4AfZ-0iL P f , t4 74 ,Q�u rt 91 n.(re:r ro - i WMW I�AX /41V4— i i NI.+rAC�►'SG�Z ..cervi DEPARTMENT USE ONLY Application Accepted BYI'`_ �. ,_ Dae I +� I �r Area + Grovi Inspection BY iDate--- P M`F'IAepectlon S tae Deetructlen Impaction BY Data Comments ACCOUNTING ONLY AiD1 FAC* ) PE CODES FEE INFO AMOUNT REMITTED CHECKO/0"M RECEIVED BY BATE I POWITISPRVICE REQUEST NUMBER INVOICE f i