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0IAPPLICATION FOR WELLIPUMP PERMIT 14 N JOAQUIN COUNTY PUBLIC HEALTH SERVICESO ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 I209I 468.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ORIGINAL ICBmpIAtA In Tripl'IAatA) APPLICATION 19 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THI8 APPLICATION 18 MADE IN COMPLIANCE MTH SAN JOAQUIN COUNTY DEVELOPMENT TTTLE,CHAPTER 9-11111�5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SSEERNCES..�ENIMPONMENTAL HEALTH DMSION. JOB AOORESSIOR APNI I.C1I7�17�t�}5 "JC/f—I%ci- �l�Tev ✓✓I I to I C� �t`/ LU- ItkQ:. PARCEL e AM/ I`a -C' GE---] OWNER'S NAME �'T"'1Y�1 ! '^" {-r / /<^'�/A'� ADDRESS LQI <. �k_CrNL _'lljC �II / IQ��I- DI C. -" CONTAACTOP l I I Z 110 1 11 I-L L� ADDRESS RL'c`ef l Yi'I r CCA UCI .J 3PHONE/ �J�s 4 SUBCONTRACTOR S�eC N �X (LY'CL ADDRESS .JICCK- CP\ r CC, LICJ`51 WJ PHONEJ 4(s -!5712, TYPE OF WELL?UMP: ❑ NEW WELL ❑ REPACEMENT WELL IJ,,J MONRORINO WELL J K- D ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS{ONNECT REPAIR ❑ VAMP EXTRACTION WELL I ❑New❑R«dr H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL O (TYPE OF POMP Cl OUT-0F.SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A / ! L ❑ INDUSTRIAL ❑OPEN IBOTTOM NG , CIA.OF WELL EXCAVATION II H,I IT J ^ mA.OF CONDUCTOR CASING D Cl OOMESTIC/PRIVATE alv O FAC%/SIZE I, TYPE OF CASING/STEEL. `V rO SClq CL(I11GT' DIA.OF WELL CASING D Cl PVBUC/MVNICIPAL ❑DRIVEN tti C1�L DEPTH OF GROUT SEAL 0_4-0 / p'i S SPECIMAT1ON 8 ❑ IRPIGATION/AG Cl OTHER 5aNd Y I I FCC GROUT SEAL INSTALLED BY 15pec 1. a Wl GROUT BRAND NAME N e4 t" C e,"e"-r E dMONTTORING Pa Lk GROUT SEAL ROMPED: ®Y. ❑M. CONCRETEPEDESTALBYDRILLER: Y. ❑Ne S 1 APPROX. DEPTH 7 b / ci / LOCKING CMESTER SOX/STOVE PIPE A'hCYZ LT'(l CPAAple}T c"✓t s RMOMSEO CONSTRUCTIONN LI METHOD: MUD ROTARY AIR ROTARY AUGERV'CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THE APPUCATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES.STATE LAWS,AND RULES AND 4EGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT-9 SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH [MIS PERMIT 18 ISSUED.I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-1 COMPENSATION LAWS OF CAUFOMIA." CONTRACTOR'S MRNOG OR SUS-COMTAACMNG SIGNATURE CERTIFES THE MUOMNO: - I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMR IB ISSUED. I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUMPNIA.` TH�E,A.PPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INAPECTIONA AT Ibj ASS.H22. COMPLETE DRAWING AT LOWER AREA PROVIDED. q slow % `V ' TM. Fvt kPeci-- f/L L VI Pew C— o.\. Q-' ROT RUN IOr•w Ie%. .l 6aMe 'Ie 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. A, LOCATION OF HOUSE SEWAGE OISMBAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. D. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS VIRHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. . ..... .. `y12 �Ja _ II DEPARTMENT USE ONLY Applb.\bn Acv«IeE BY Grave Irnp«teen By De\. Ptmp Imv«teen BY Otle De•bucllan Imo«\Ian 8y DKe ACCOUNTING ONLY: AID/ PAC/ PE COO" FEE INFO AMOUNT REMITTED CHECK/MASH RECEIVED BY DATE PGRIMITISEIMCE REQUEST NUMEOR INVOICE I i