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APPLICATION FOR WELL►PUMP PERMI' SAN JOAQUIN COUNTY PUBLIC HEALTH SEM, AS ENVIRONMENTAL HEALTH DIVISION P.O.BOX 388,%X EAST WEBER AVENUE,STOCKTON,CA 95201.988 (209)460.3420 j NOM-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED - (Complete M Trip&eu) [/�/ 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 COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR"NI 2969 Loomis Road cITY Stockton PARCEL SIZE/APNI 17 9-1 1 0-2 a OWNER'S NAME John & Mara'aret Marci ADDRESS 2973 Loomis Road PHONE#209-946- CONTRACTOR vkw nrillin ADDRESS__P0 PQx 53.Rio Vis}}� 0674 `} -I 11C� 71 nf,7RPHDnnNEf SUB CONTRACTOR ADDRESS i7/ LIC# 7ZJj i 74-2815 TYPE OF WELLB'UMP: ®NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL/ �❑IpOTHER El INSTALLATION 11 WELL SYSTEM REPAIR 11CROSSCL. CROSS-CONNECT REPAIR d VAPOR EXTRACTION WELL/ 1-4 ❑N—El Repair H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL 0 (TYPE OF PUMP( IIS� 11OUT-OF-SERVICEWELL ❑GEOPHYSICAL WELL I El SOIL BORING g ❑DESTRUCTION: INTENDEO USE TYPE OF WELL CON/TRACTION SPECIFICATIONS A ❑INDUSTRIAL {7❑� OPEN BOTTOM DIA.OF WELL EXCAVATION 1011 DIA.OF CONDUCTOR CASING 0 11JI DOMESTIC/PRIVATE GRAVELPACK/SIZE_.Pg-a TYPE OF CASINGISTEEUPVC FVC DIA.OF WELL CASING 41, D ❑PUUXMUN'CIPAL ❑DRIVEN DEPTH OF GROUT SEAL 28, SPECIFICATION R ❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAMEE 11MONITORING GROUT SEAL PUMPED:®Yr (IN. CONCRETE PEDESTAL BY DRILLER:n Yr ❑No 5 APPROX.DEPTH 70' LOCKING CHESTER BO%/STOVE RPE Flush Mount BOX S PROPOSED CONSTRUCTION/DRILUNG METHOD:MUD ROTARY AIR ROTARY AUGER X CABLE OTHER 1 HOWRY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES ANO REGULATIONS OF THE SAN JOAQUIN COUNTY.NO E OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PER NS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFO ANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPFNSATION LAWS OF CALIFORNIA.'THE APPLICANT MUST CALL t NO S IN ADVANCE FOR ALL REOLMLily1N FOTNINS A 20e14404422.COMPLETE DRAWING AT LOWER AREA PROVIDED. SlPrwd% T \_--� �/l 7PLAN .w {`- Dm-� i• PLOT AN IDr <.S".)S-1. -1 •tp 8 0' 1.NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4.LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OP 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. IL D 0 c-1l�K�tirtON lowwMNa . ........ . .: DEPARTMENT USE ONLY _ Applketbn Accepted BY .. L Arr Gantt I-P—I..BY D.ts Pump Ivpmd-By DAN Deettuctlon l wpeetll.BY Oeh Commente ACCOLMHTINO ONLY: AID/ ''''� FAC. PE COD" FEE INFO AMOUNT REMITTED NEC\CA.H RECEIVED BY DATI PORMIT/SEANCE REQUEST MUMS INVOICE