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APPLICATION FOR WELLIPUMP PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SER ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON. CA 96201.388 (209( 468.3420 NONREFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (COM APPLICATION IS HERE By MADE TO THE SAN JOAQUIN COLINry FOR A PERMIT TO CONSTRUECT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMIYT TITLE CHAPTER 9-a 7 $ AND THE ANDARDS OF SAN JOAQUIN COUNTY M13UC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNN x?-6 -t- STGEI<T n! - nL„�,�U, a'' Cm 5 Te>LJr-r.....1 PARCEL SIZE/APNN OWNER'S NAME [,/» TIME (JIT C �CH�IvI� C<%ytawlrF E_ T 4 ADDRESS 27 W - SFiI;r -,4 7�Y CONTRACTOR GyyL 1ZK� �LyO PHONEN ADDRESS.S 4.} 4.-8;l UCK NA 4� SUBCONTRACTOR IAIE'S'T LtAZ—A-r C>di4 327J /ary��1yT^� PHONE N_ 37[•stj ADORES S SMLq 1lP.,i71cs7- git; G f UCN Sg-4 l Jcf PHONE k '72 76 TYPE OF WELLR'UMP ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL N ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL X U RYPE OF PUMP? 13 N.EJJRepalr M.P. DEPTH PUMP SET__FT, FIRST WATER LEVEL O �0 �te�MQ�O�U(T��pFSEgVIC-E�/ELL I ❑ GEOPHYSICAL WELLN I N+�ry� ❑ SOIL BORING B DESTRUCTION: ML,.,1Ti.2 t,./( -" DVz .�.., Z 4 INTENDED USE TYPE OF WELL CON6TRUCTON SPECIFICgTIONB /r ❑ INDUSTRIAL ❑OPEN BOTTOM C '4r� DIA.OF WELL EXCAVATION_ (71( IVIOr�I -I'O T'I✓LR WF Q L-S A ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE O CO D CTOfl CASING D ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT S EEL/PVC FPC.. —� DIA.OF WELL CASING 4-trey O DEPTH OF GROUT SEAL � ❑ IRRIGATION/AG 119THER SPECIFICATION 40 R ❑ MONITORING r n I e-U/Y,Qj2-(S GFOUT SEAL INSTALLED BY. SGROUT BRAND NAME Mn- I� ''`G i SEAL PUMPED: ❑Yw ❑No E APPROX.DEPTH '3O FT — /•W l) I TD�• nAt yy Q CONCRETE PEDESTAL BY DRILLER:Ely. ❑No S o LOCKING CHESTER BOX/STOVE PIPE PROPOSED CONBTRUC ON NG M�TNp� 1A D TNM `� S LAR ILL. ( MQ\SQr(�`� AIR ROTARY AUGER Jc CABLE 5 F PiCJti4+(r5 L✓1"b.l SEE OTHER I HEREBY CERONS IFYOF THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE V/ITH SARI JOpOU1N COUSNTY ORDINANC8,44-1cES,STATE lAWB,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 WON(FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRgtTOR'S HIRING OR SUB-CONTRgCTOF 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 INGCOMPENSATIONSIGURE CALIFORNIA.- THE APP CANT MUgT CALL N HOURS IN ADVANCE FDR ALL REQUIRED /INSPECTIONS AT 1-"9114853 n- COMPLETE DRAWING AT LOWER AREA PROVIDED. CAWS OF SlllneE TIUa Ly e T PLAN 6cNa)Scale I " 1. NAMES OF STREETS OR ROADS NEARESPROPERTY, (Draw to R BOUNDING THE PROPERTY., to I JC 2. OUTLINE OF THE PROPER ,GIVING DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS. ,AND WALKS. b. LOCATION OF WELLS DJON RADIUS PE ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS a ON THE PROPERTY OR ADJOINING PgORry, P05 T` FAci i 1-T.y uP r o Iccailr S 1 it DEPARTMENT USE ONLY Application Accaptetl BY Grout IMPactlon by Data 5 1 Pmp Irupaction By _3 9L Inption BY t Date - -3 J � 3 '5,11&Es Dna Commets 10 WJ " s/ H o 30/ � ' 9� ACCOUNTING ONLY: AID# FACN PE CODES FEE INFO AMOUNT REMITTED CHECKN/CASH 11ECEI ED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE a Co- I ","(0Lf,?,75 s/a 1 �