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APPLICATION FOR WELLIPUMP PERMIT"' %%w SAN JOAQUIN COUNTY PUBLIC HEALTH SER*VotS ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-88 1209) 461.3420 NOW-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in TFIPlie$te) APPLICATION IS HERE BY MADE TO TILE 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 fTTIIT�LE,CHAPTER 1x115.3 AND TH STANDARDS OF SAN JOAQUIN COUNTY�PUBLIC1H_EALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOBADDRESSIORAPNI^� I 01 �J71T�ItIC_. A V`'.-- _- — CITY—tncK4,zn - PARCELSIZEIAPNI OWNER'S NAME_L.A-t U l *:� l�� ADDRESS .! \t nC ovil CL50"l PHONE 0 7 .�.�'l� �+tf t'0-- CONTRACTOR G ADDRESS O IV, At r-, LS C# R�L �� PHONE/ (1 101 L t1/ SUB CONTRACTOR 11-ftQ,I1 [JI'�,11a'+�� rft/ ADDRESS ' ^. Z ('S d�" t' LIC4 V�1 b1'� PFIONE/lrC'8J� 1.77Q TTS TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL %MONITORING WELL ItAti ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J ❑New❑Repall H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-OF•SERVICE WELL ❑ OEOPHYSICAL WELLS ❑ SOIL BORING B ❑DESTRUCTION: INTENDED Use TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION f i/ _ OVA.OF CONDUCTOR CASINO 014 O do 1:1DOME9TIC/PRIVATE IR GRAVEL PACKISIZE II 5WO TYPE OF CASING/STEEL VC) 1 Z« YTS i- - ___ DIA.OF WELL CASING f rIO ❑ PUBLK:/MUNVCIPAL ❑DRIVEN DEPTH OF GROUT SEAL�e T4�� SPECIFICATION :Ci0tJI1t1L ,1tN R ❑ IRRtGATION/AG ❑OTHER GROUT SEAL INSTALLED BY 1* I)Ef GROUT BRAND NAME.-I frimA. I To-TL E 9 MONITORING GROUT SEAL PUMPED: 0 Vr ❑No CONCRETE PEDESTAL BY DRILLER:AYeo ❑Ne S APPROX.DEPTH 'Ir LOCKING CHESTER BOXMTOVE PIPE_ y -_. . S PROPOSED CONSTRUCTIONIDRILLINO METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK 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 FOA WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERT fF1ES THE FOLLOWING: '1 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 CAUFORNI�APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REOUIRED tNSP1?CT10Ns AT 120$1 4494W2%. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slanod x Pula _ U o Ja y!y-'{ ..._....,._.. Dote_�0� PLOT PLAN IDrow to Scale)Scale '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 OUTLINES 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, i DEPARTMENT USE ONLY Application Accepted ByN& zLDate 7.24.,q 'I-) Grant Impaction By Dote Plenp Inspection By Date Daetructlan Iro/peatlan BY //�� // �/},�� Daattaf Comments lJ �PK IK 1.1 t C.]1L�..F� I t v uu �^luY y ECS l� V 1 r IO docc�b(..0 QQvrvu�� 9� ACCOUNTING ONLY: AID/ FACR PE CODES FEE INFO AMOUNT REMITTED CHECKI'/CASH RECEIVED SY DATE PERMIT/SGI ICE REOI/EST NUMBER INVOICE 35dZ t 7.2LA 3