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` APPLICATION FOR WELLIPUMP PERMIT *SAN JOAOUIN COUNTY PUBLIC HEALTH SER& ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468.3420 NONREFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) 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 TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRE88IOR APR/ t"+ rN�/ V NE•` CITU [,O PARCEL 812E/APR! 1, // L 57 le JF �,TL IVR/YIe*P C�� ADDRESS RIO �' /Q AJ� '4�_ ON /_ Z�3 OWNER'S NAME L / u/ I R10NE• CONTRACTOR �M�C I S I O'/U SQ 0'YI/C//UC -ZNaAt)Q ESI 31, O 'e, /7K�s �/Cl PHONE l /zt/owl SUB CONTRACTOR ADDRESS UC/ PHONE l TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL '!t OTHER C>fYi �PC't L it ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ ✓ ❑Nm ❑Sepal, N.P. DEPTH PUMP SET-1:1'. FIRST WATER LEVEL 0 (TYPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL! ❑ 801E BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION GIA.OF CONDUCTOR CASINO D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASINO D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E MONITORING a+� / GROUT SEAL PUMPED: ❑Y. [IN. CONCRETE PEDESTAL BV DRILLER:❑V. ON. S APPIIOX.DEPTH J O LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTIONMAILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HMSY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- TT/_HE APPLICANT MUST CCAALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIO/NS AT 120151 411111 COMPLETE DRAWING AT LOWER AREA PROVIDED. /+ Stencil XP 1pflU n (� /Z/7Tllle �(�Cl' O /S( j L� Dan C� 7 PAT PLAN Mr.to Sahel Scala '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 OUFUNFS AND LOCATION OF ALL EXISTING AND ROPOSED 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. See le M9� DEPARTMENT USE ONLY Application Aaceptetl By / F ,L Groin Impaction By _l Data Pomp Impaction By Data - Data Dstrmtlon Impaction By Comma n;23L— aQpra�cL_Q a191y d�hsn� (2 )4 D33301n�si `lBh✓s lvladL>aF �n scled�(o a1g I+1.S on b I�tK flip ACCOUNTING ONLY: AID/ FAC! PE CODES FEE INFO AMOUNT REMITTED CHECK!/CASH RECEIVED BY DATE PORMIT/SERVICE REQUEST NUMBER INVOICE a DI 321 5.23�� X04'