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APPLICATION FOR WELL)PUMP PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SER* ENVIRONMENTAL HEALTH DIVISION BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 )209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (CompMtE in TrOlkntE) APPLICATION 18 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 ADDRESS/ORLAPNI ©� �hn�,�//�j^ C/1--1 1�[T D PARCEL SIZE/APN/ K. _- _ OWNER'S NAME'TT(//� FM'I jTJE`!= L-GlI✓I ��✓ / 5. 'jp ,�T�ZFjvPJ �i u7L ADDRESS (/�-. �� >' -5� PHONEY, 7 CONTRACTOR(,/GL.TA FeV✓p-,OVTe1,�>Iij Nj_ �pnv:J/ L' GJL.�D r/PvrP 2 'i1�Zcc' n i/ pp�� "�YI'�i ADDRESS PHONE/ j, '-�-vp SUB CONTRACTOR VA1a•zMStt_ ADDRE88 > NCI G4Z6/ '7 T ♦ v TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL KIMONITORING WELL I ! ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLi ❑ (TYPE OF PUMP New❑Rep.ir H.P. DEPTH RUMP BET FT. FIRST WATER LEVEL 0 ❑ OUT-OF-SERVICE WELL GEOPHYSICAL WELL SOIL BORING S ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION$,/ A 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION "O t �1�L V� DIA.OF CONDUCTOR CASINOOI�O D ❑ OOME3TIC/PRIVATE �MVEL PACK/SIZE TYPE OF CASING/STEEL/PVC Y V L DIA.OF WELL CASING s(i //T D ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E �MIINRORING GROUT SEAL PUMPED: Ely. ❑Ne CONCRETE PEDESTAL BY DRILLER:❑Yr ❑Ne S APPROX.DEPTH ..�sr�I j / LOCKING CHESTER BOX/STOVE PPE PROPOSED CONSTRUCTIONIdOWNO METHOD: MUD ROTARY glfl fgTARY ' AUGER — CABLE OTHER A \J\I 0ZffkIlV I HPIEBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS, ND'RU 8 ANO REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE E THE AND FOR WHICH THIS PERMIT IS ISSUED,I SMALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -I CERTIFY THAT IN T""1'61 PERFORMrCE OF THE WOR(FOR WHICH THIS PERMIT IS ISSUED,I SMALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF C4JJUFOBNIA.' HE RIC IT M, ST W 2a IMI IN ADVANCE FOR ALL REQUIRED IN(t/�J/C�TIONS AT 120S11M//y�}.,3]/.�CCU PLLETE/DRAWING AT LOWER AREA PROM D. 81pr�d/1I(L//JJ Tli / /" L'Z lJ/CC��C'VL�SDn. ✓ PLOT PLAN(M.w to Sine)Scale 'to 1. NAMES OF STREETS OR ROADS N REST TO OR BOUNDING THE PROPERTY. ♦. 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 OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. 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. .. i.. _ l ......i .. ..'.. ._ .:. .. :... � �.a..r Cr/...... 0 . ... \/{��//J� DEPARTMENT USE ONLY 9 Appllee0on Accepted BY / V L Det. C Grout impeotlon By Dae Pump Impectlon By DMs nw'uetlon Impectlen By D.I. D.mment.: ve✓ 6r00"\) et�l-'fd m"W1 I tV 5 w/ 6!dd a f- L.Odt' ay 1 M VI o n s— ACCOUNTING ONLY: AID/ FACT PE CODES FEE INFO AMOUNT REMITTED CHECK(/CASH RECEIVED S DATE PERMIT/SERVICE REG EST NUMBER INVOICE 0 24 �5a q5'91 510