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APPLICATION FOR WELL)PUMP PERMIT �. JOADUIN COUNTY PUBLIC HEALTH SERVICLI ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complots in Milliebtsl APPLICATION IS HERE BY MADE TO TME SAN JOAGUM COUNTY FORA 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 THE1 STANDARDS OF SAN JOAQUIN COUNTY {P�UB�LI1C'H.�EL(AALLTT�H SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# n S1,�� + urr"aV 1 `^^" CITY J"'�'f'� ry_ PARCEL SIZE/APNK SeHll#g D C12AYLT►3 $p 9 ADDRESS G � V,l oCq 4 1Io08- 182 PHONES 5ro (P52'45D0 OWNER'S NAME O LIC# PHONE# 013 CONTRACTOR '-I � AODRE66 1/V- V5 T"111 Y1G ADDRESS StLC45' Ak CA,stcpD` UC# G SUBCONTRACTOR t -4IoEI PHONE#�#7•oW31�� .^,y TYPE OF WELLR'OMP: 11NEW WELL El REPLACEMENT WELL ❑ MONITORING WELL# M OTHER L 11W I ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPORE... ❑New❑Repair H.P. DEPTH PUMP SET-17. FIRST WATER LEVEL 0 (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELLX SOIL BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ��••�� A 1:1 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION V, DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC DIA.OF WELL CASING L D 11PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEALJ467 ?Igo SPECIFICATION bZlyt I7R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED By �IlZeK5 GROUT BRAND NAME E ❑ MONITORINGLLLL.��f GROUT SEAL PUMPED: 19 Yea [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr [IN. S APPROX.DEPTH H-b- O LOCKING CHESTER BOXWrOVE RPE s PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT TTHE 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 WORK 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"APPUCA T M T CAI�(y�y Q4 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTON(S AT I�eSI 48 23. COMPLETE DRAWING AT LOWER AREA PROVIDED. Dnp SIoroJ% V'" / � 'YILI Title PPD C( C O {s t DNe �// /�/ PLOT PAN Qrsa to Scale)Suis 'to 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 OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTUNFS 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. 3ON8Ay 29W9 u i 3v°'3 8 XRT a y 8 a I _ a oo0 6 to U ee • ie PY08 N700M17 9 ' m� r }ua0sa?TauOj uarinyw.}g IL �� DEPARTMENT USE ONLY Application Acceptetl B Deta Grout Inspection By _ Date Pump Inspection By Data Destruction Inspection By Date Comments ACCOUNTNO ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERAIMSERVICE REQUEST NUMBER INVOICE 29 o f 89 3G (P 6