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APPLICATION FOR WELLIPUMP PERMIT SAN JOADUIN COUNTY PUBLIC HEALTH SERVIC ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST, STOCKTON, CA 96201-388 (209( 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDMJR INSTALL THE WORK DESCRIBED.THIS APPLICATION I6 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9.1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOBADDRESSMJRAPN, 2401 Mac Auu rtkr+ n ;VU T CITY rntu J.( //�1 PARCELSMAPNI 2./3-A¢0--50 OWNER'S NAME LQQN ✓Ln FO OJS TNL ADDRESS 240) M4L AN/hY OR ;y/ . PHONE O' - 40 CONTRACTOR ly]G�I�(� QN;HIAQ , ,-r-Mr ADD1E66 "NA NoAland 9, CA LICA 20G2_91 PHONEI(9/(0)�ISS-0�zqZ SUB CONTRACTOR ADDRESS LICJ PHONE. TYPE OF WEILPUMP. ® NEW WELL ❑ REPLACEMENT WELL ❑ MONITOPNG WELL, ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CRGSS-0ONNECT REPAIR ❑ VAPOR EXTRACTION WELL t J ❑NRuv❑PePar H.P. DEPTH PUMP ST—FT. FIRST WATER LEVEL 0 (TYPE OF PUMP ❑ OUT-0FSERVICE WELL ❑ GEOPHYSICAL WELL f ❑ SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION& A ® INDUSTRIAL p❑Iq1 OPEN BOTTOM DIA.OF WELL EXCAVATION / I� DIA-OF CONDUCTO0.CASING D ❑ GOMESTTCIPORyVATE GRAVELPACKISRE )D�IZ /STEELJPVC TYPE OF CASING .S+Atdj SID Fes. DIA OF WELL CASING � D ❑ PLIBUCMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL I0, SPECIFICATION R ❑ IRNGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY Dr`I II C✓` GROUT BRAND NAME E ❑ MONITORING I GROUT SEAL PUMPED: my— ❑N. CONCRETE PEDESTAL BY DPLLFR:❑Yr ❑N. S APPROJ DEPTH LOCKING CHESTER 50X OVE PP 5 PROPOSED CONSTRUCTION/pDWNG METHOD: MUD ROTARYJ/ MR ROTARY AUGER CASLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY JRDINANCES,STATE LAWS,AND RULES ANO REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMIW'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUS{ONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA..-)/ 1_E APPLICANT MUST CARLL M HOURS IN ADVANCY FOR ALL REOMREU INSPECTIONS AT 120511ABBJ4= COMPLETE DRAWING AT LOWER AREA PROVIDED. SlPlnd X /�!l/Y1/YI.A' 1/- D TIM. V C�/CJ� PLOT PLAN ID—w Sinal 6w1.�_'t0 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUNE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. O. 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 PHOPERIY. 5� TE l ANcl Wyk pry ,,/� DEPARTMENT USE ONLY G G, AP~.Aa.Pud B�L[//�✓ D.I. `'/'Z�'' /. J A,.. G,.BRP.N.R Br D.m PumP In.P.a1.n Br Due Dst,u —N-Pe .BY bu d o c v�u n E :,J L(x)yy- ACCOUNTING ONLY: AID, VV FACE PECODE, FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED SY DATE PERMITISER1VVIICE REOUE11T NUMBER INVOICE