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i APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVILt'S ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAOUIN ST., STOCXTON, CA 96201388 (209) 4683420 NON-REFUNOABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APRUCATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDOR INSTALL THE WORL 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 ADDRESSOR APN# Z`103 W 1.14 V y D r. CITY S PARCEL�SIZEIARMI —S owNER's xAME —ADDRESS Rte 1< Qa..l Ly Ler-p . SSS wA11' TcYr BLOWY, N 10 �)4:. s Q. y PONEI Qlv CONTRACTOR SM IL" � 4 e�r 01 ADDRESS 1 L60 L'ISQ"12 S 01 •'EIV LIC# PHONE# S19-22.21 4,"3 C SUBCONTRACTOR UIt'e w_Y ADDRESS 1-45t .. C '• L_.4 LIC#102 9 0 PHONE#41S -I O(c TYPEOF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑N.❑R.,Y, H.P. DEPTH RUMP SET-17. FIRST WATER LEVEL O TYPE OF PUMP) ❑ OUT-0E-eERVOE WELL ❑ GEORIVSICAL WELLR � 801L BORING ❑DESTRUCTION: VVVIII INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL 11 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTICAANVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEEIN C DIA.OF WELL CASING D ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION A ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: 11 Y. ❑N. CONCRETE PEDESTAL SY DRILLFR:❑Yr. ❑N. S APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE 5 PROPOSED CON&TRUCTIONAIPEWNG METHOD: MUD ROTARY AIR ROTARY AUGEfl CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK VALL 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'S COMPENSATION LAWS OF CAUFORWA.• CONTRACTOR'S HIRING OR SUBCONTRACTING SONATURE 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 COMFEN&ATION LAWS Of CALIFORNIA.- THE APPLICCAANT MUST CALL M HOURS IN ADVANCE FOR ALL REQUIRED INSSPPECTION&AT 130.14483423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Sin+.JX �..�-. c3T-.-s �'"�^A Tin. Yro\ ��wL0a15� Dns zlidl47 PLOT RAN(D,.w W SCM.)Sul. •to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNCING THE PROPERTY. 4. LOCATION OF MUM 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 B. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY IT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PSOPERTY OR ADJOINING PROPERTY. I IH I;I � a \ = a z zoo ~o w \ LL W Z V 8 W U a f S• . HU YY o O { Be • � 1 I• Y 9v-9EE-t6 wn n = a DEPARTMENT WE ONLY Application Aucpte!By / Groin IropntlCn By Got. Pump imp tion By D4L• 13--6on Iropmtion B - cpmm.nt.: `JolI 0D, rl 5 l,� y)/Y> - ic' iir41G (nJ /lgr�.t{-- �.1✓le✓1 Hon W1 A s �+ za, q�� 0�3 10 )orK-Ln d rLo� ACCOUNTING ONLY: AID# RAV ME CODES FEE INFO AMOUNT REMITTED CHEC"MASH RECEIVED BY DATE PEIYAITISSIMCE REQUEST NUMBER INVOICE 3�o r61 1120 X11 212.9