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APPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388,446 N.SAN JOAQUIN ST.,STOCKTON,CA 96201386 (209)4683420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNT/DEVELOPMENT TITLE,CHAPTER 9-11115.3 AND THE STANDARRDS}OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. S `;nJOB ADDRESS/OR APN+ i 42 io u-�'1-. l,1 n I,)n CJI IXTY qoe u'/ PARCEL SIZE/APN+ 44iii —40— OWNER'S NAMEorTTri6L--JGOPFSS I .�y� �'+� cRAcroa V W C 11 t n n ADDDD{(RESSSSP(�- S LIC+1 t.S'��IO(o oNE+j07 3-74 2815 1�� I'T� 11�" I►Y(/N tgDRSEtO.)1 �� 1{ �If9e� PHONE+ TYPEOF WELLJPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL+ ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL I J ❑New❑P—j' H.P. DEPTH PUMP SET_FT. yyFIRST WATER LEVEL 1 O (TYPE OF RUMP) pl SOIL BORING U 3 bOC H/�c�S B ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL+ J' ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION P3 1 h r DIA.OF CONDUCTOR CASING NA O ❑DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVCDIA.OF WELL CASING NA O ❑PUBUC/MUNICIPAL El DRIVEN DEPTH OF GROUT SEAL 'V ZS :& SPECIFICATION R ❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY A(1 I ID f GROUT BRAND NAME ria CF> 1 E ❑MONITORING `` GROUT SEAL PUMPED:❑Y- ❑No CONCRETE PEDESTAL BY DRILLFR:❑Yr ❑No S APPROX.DEPTH Fr J t-GY T LOCKING CHESTER BOX/STOVE PIIPPE S PROPOSED CONSTRUCTIONIDWWNO METHOD:MUD ROTARY AIR ROTARY AUGER Jl—CABLE OTHER I HEREBY CERTIFY THAT 1 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:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES ; THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA/'/y'/ /CANT M,U/S/},CALL 2/1/(N//(�p,8 INN ADV/A_NCE FOR ALLREQUIRED INSPEC NS AT 127e14W3423_.COMPLETE DRAWING AT LOWER AREA PROVIDED . SlSnodX [ ,//�.f,!/� ,� / ///T/1..�/ Title ��/t7/i J� 4 D.. ROT RAN ID'—to".lb PLOT RAN(Drew to Seel.)Sulo 'to 1.NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING 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 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. c -a' PestiIt R D ARTMENT USE ONLY I ApplkRlon Accepted BY .-/ � D.te G—Impaction By D.I. Pump Impaction By D.. Dstruction Impaction By D.I. Cammant.: ��/ i� T 2i��! L f�j 4Ca Y -3qf GYM{ �x 'yL�'L�C (11 Gf EC7�"{Q ACCOUNTING ONLY: AID+ FAC+ PE CODES FEE IN AMOUNT RFMIMEED CHECK RECEIVED Y DATE PERMIT/SERVICE REQUEST NUMBER INVOICE