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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 96201388 (209) 4683420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CDmpIntn in TFOR0110) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TTTLE,CHAPTER 9,1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADORESS/OR APN:F 7 A Av Dr-7w E CITY y] I O C(G7D'j PARCEL SIZVARJt SLS S,FZbu cas k4uk S foot OWNER'S NAME /� �ALZF�e.. F NEQfADDRE55 g y LR/) ST. 'CRONE N CONTRACTOR C'T11.J}E r ewax(t(Mai -- AN c/ ADDRESS _ ro(Llc12 �t/� A?X77 ucI/IZ t�p P EI �I� SUBCONTRACTOR �A, ADDRESS UC2 PHONEI TYPE OF WEUJPUMP: -<NEW WELL ❑ REPLACEMENT WELL AlMONITORING WELL 16" I,7' 3 ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL t ✓ ❑Nerv❑Reyelr M.P. DEPTH PUMP SET-FT. FIRST WATER LEVEL O (TYPE OF RUMP ❑ OUT-0F-SERVICE WELL ❑ OEOPHVSICALWELLI ❑ 601E BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O ❑ DOMESTIC/PNVATE GRAVEL PACK/SIZE 3 &k J TYPE OF CASING/STEELIPVCy CIA.OF WELL CASING 2E D ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R (�❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E .&MONITORINGI� C F GROW SEAL WMPED: 11 Y. [IN. CONCRETE PEDESTAL BY DRILLFR:❑Vr 0140 S APPROX.DEPTHa J LOCKING CHESTER BOX/STOVE RPE s PROMSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY 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 WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN%COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-0ONTMCTING SIGNATURE CERTIFIES THE I I CERTIFY THAT IN THE P RPoRMANCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUM IA.' TXE PPKANT MU CALL NO N ADVANCE MR ALL REQUIRED INSPECTIONS FFAT 120514583423. COMPLETE DRAWING AT LOWER AREA PROVIDED./-T 9�L\�- BIEM X Tit]. DSM Z� • "' PLOT PLAN IDI to S e)SUIe I 'w 100' 1. NAMES OF STREETS OR ROAD ST TO OR BOUNCING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROMSED 2. OUTLINE OF THE PROPERTY, NG DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTUNES AND LOCATION OF ALL EXISTING AND PROPOSED 5. 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. AtA I 0EA0 WELL LDC—IzOd