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APPLICATION FOR WELL►PUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION •4 �Q �O P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 (2091468-3420 '11.1N 1995 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENr?p PLN ICompl6t6 in Triplicate) (��NTM APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IH�IR7�rryy��77, JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISI�H SAN JOB ADDRESSOR APN# Q ri n T n r�t i c+-r-0 i s j 9 PARCEL SIZE/APNI OWNER'S NAME Marian Mnhr 1+'r Tlr , yP C1 c�F � �an h s c 0a Jery�y - ADDRESS O U 1 PHONE 1 .t.�,t .� M rtle t `� �-�-- 808 coNTMCTORfi=P r t.r l I m F.x r 1 n r a t i o n R T n T- ADORES l y # �1 7 7 ti R PHONE ADDRES 11 W_ Evelyn #3Q5 �ONt�S-062: 12,�,{ ant : Cypress Environmental _ 4=676' TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL 1 OTHERT;a I' 3 $e r"g s ❑ INSTALLATION 11WELL SYSTEM REPAIR 11CROSS-CONNECTREPAIR ❑ VAPOR EXTRACTION WELL# ��--7A"'` ,� ❑New❑Repair N.P. DEPTH PUMP SET Fr. FIRST WATER LEVEL n["'TAe\ O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BONNO S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASING D ❑DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO p ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E M MONITORING GROUT SEAL PUMPED: ❑Yes [IN. CONCRETE PEDESTAL BY DRILLFR:[3Y. ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRIWNO METHOD: MUD ROTARY AIR ROTARY AUGER X CABLE OTHER I HEREBY 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:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SU"ONTRACTINO SIGNATURE CERTIFIES THE FOLL Q- *1 CERTIFY THAT I THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF C IA.' HEA C NT MUS CALL 24 HOURS IN ADVANCE FOR ALL REGUIR NSPfGTONS AT 20191 46/�}7� COMPLETE DRAWI O AT LOWER AREA PROVIDED. ry /� �S i fl-4t.��Q�GSS t rlV i(1�t W�Gk.'1M•-r Slp ill... Title Ft4 L1�-I, �[ UIM XO(oraT(Ili. lkL. Date u N PLOT PIAN(Oraw to Style)Seafa_ •to 2Co/ 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 6. 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. :. ... ...i. _ .... .. `.. ...:.. �►.1�Sr�R1APl-�RIdE'.. .......... DEPARTMENT USE ONLY Application Accepted By Date ! J Area . Grout Impectlon By Data.Pump Impaction By Date Destruction Impaction By Date Comments: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTEDCHEC rASH RECEIVED BY D TE PERMIT/SERVICE REQUEST NUMBER INVOICE J - 1, dd 02,