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* APPLICATION FOR WELLIPUMP PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SERO ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (209) 468-3420 NON•REFUNOABIE PERMIT EXPIRES 1 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 COUNTY DEVELOPMtgT TITLE,CHAPTE 1115.3 AND TIE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNN P T• KT - C S CITY S-TCT.K TCJt�i PARCEL SIZE/AM# S-Tr�CK'TWJ T1=�n,1,..,AL TF��J:cq` SEAT-,-Lr= Wq OWNER'S NAME CIO r+ 'Tr,Ar- OLS C - ` A r y C ADDRESS 1! }XT W Cori - W4 tIj PHONE# 2-7r p� CONTRACTOR FMIL Le,N, N33 wf hrA2lst-F' F3-v 1�p ADDRESS SA47hw1Fa1T t]A 9cY5i4 LIC# IIIA PHONE#9/S i.NC'0 SUB CONTRACTOR W IF>7 (JA y,4—r 0121 ,-c '_ 3'Z33 GTrZCrE�A+ G S l- %/G c'SET ADDRESS 5.+%n^ C-A UC# SS¢979 PHONE#___:22-7&, 9r z TYPE OF WELL/PUMP: ❑ NEW WELL ,REPLACEMENT WELL •Ile MONITORING WELL# {>$ 6�IG-Z> m❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR / ❑ VAPOR EXTRACTION WELL x TYPE OF PUMP) 1:1New❑Repelr H.P. DEPTH PUMP SEF FT. FIRST WATER LEVEL O ❑ OUF-OF-SERVICE WELL 11GEOPHYSICAL WELL ❑ SOIL BORING S 11 DESTRUCTION: IN TEN OED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL 13 OPEN BOTTOM DIA.OF WELL E%LAVATION � � A . � DIA.OF CONDUCTOR CASING N n p ❑ DOMESTIC/PRIVATE ,KGRAVEL PACK/SIZE '5R 3 TYPE OF CASING/STEEL/PVC� DIA.OF WELL CASING Z� 1 r.l a•/ p ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPFHOFGROUTSEAL 3 s FT , Z7 GT SPECIFICATION CMNT wl-r-� S-'/, I1,- u„•,q,y_ ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY T61=-,,r_ GROUT BRAND NAME E MONITORING n j GROUT SEAL PIIMPED: ❑Ys 11 No CONCRETE PEDESTAL SY DRILLER:❑Yr [IN. S APPIIOX.DEPTH—' r T / j 5 F"E LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER x CABLE OTHER — I HEREBY CERFIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW 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,I 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 WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THE A�P/P4CANNTT ST CALL 224/11,me IN ADVANCE FOR ALL REQUIRED INSPECTIION�&&AT 120816 83623. COMPLETE WING AT LOWER AREA PROVIDED. + , SlOnstl% ( T !J LC%/' ✓�rM Title /K-{' Det. A t PLAT PLAN(Drew to Scele)Socia 'to )Z J I 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 F OUSE S DISPOSAL DISPOSAL 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS SYSTEMS.ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALICS. ON THE PROPERTY OR ADJOINING PROPERTY, LV/'S i U✓j Sa�iwl=TC r,\ '. I 2m IN Al— POJ- vF I— coc- Nf a y y__ PSfKt - Zs y ( l �♦ DEPARTMEN USE ONLY lica Apption Acceptatl BY / l t -✓`V Det. /� ,Orae • v"-- Grout Impaction BY Date /J pump Inepecti.n By Date Dmor tion Inspection By L Det. Qemmmb: a � a ti.>• � �z t �,>1.Q,,��- - , s/r71125 ( ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE X90 ' a ?_s -IM67-, sz � coo � oo �