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APPLICATION FOR WELLIPUMP PERMIT OSAN JOAQUIN COUNTY PUBLIC HEALTH BERMS ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 1209) 4683420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (CompMtB in TriplicBtB) 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 ADDRESSOR APNR, 1 — ��,{v 1 I� CIT//Y CJ�/ J� PARCEL SIZE/APN(/T; OWNER'S NAME Na�PHA /'FG �L ADDRESS /ID >t / UA'.UFC� A>�O A_t) �ONEI CONTRACTOR teC1 SIO ,t/ SQ/14A4/A/6- -�ZOU(-. ADDRESS Ldp/ Lli PHONE) BUB CONTRACTOR ADDRESS .�L LIC) PHONE E TYPE OF WELLRPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL S 'iC4 OTHER 6&JO ;>1-04 ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR /❑ VAPOR EXTRACT) N WELL f J ❑N.❑Hep.lr M.P. DEPTH PUMP SET—FT. FIRST WATER LEVEL O ITYPE OF PUMP) F.aOI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I C]- BOIL BORING e ❑DESTRUCTION! INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTICR'RIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEELtPVC DIA.OF WELL CASINO D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑1 �� IRRIGATION/AG ❑OTHER GROAT SEAL INSTALLED BY GROUT BRAND NAME E �Y MONITORING / GROUT SEAL PIMPED: ❑Yr [IN. CONCRETE PEDESTAL SY DRILLER:❑Yw [IN. S APPROX.DEPTH l t/ LOCKING CHESTER BOX/STOVE PP: S PROPOSED CONSTRUCTION/DIILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE BAN 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 WOW(FOR WHICH THIS PERMIT 16 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' T APPLICANT MUST CALL 2S IgllXe IN ADVANCE FOR ALL REQUIRED IN//SPFIClI'Tb Me AT 12RN)�SSJIZS/.jCOMPLETEyOctRAVJING AT LOWER AREA PROM ED. Siprotl X TlRls !� PLOT PLAN ID,.w to S.J.1 Sub m 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. S. 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 AAS PATIOS,DRIVEWAYS,AND WALKS. TY' ON THE PROPEROR ADJOINING PROPERTY. e� /✓IQ/7 I S 74ti° 1 DEPARTMENT USE ONLY ,/�'/� /� Appllc.tlen Accepted 8 ��"��/^/ D.te + f/'3 r L Ara LJ Grpm Impectlen By D.te Pump Irnpeetl.n BY D.t. Dmvudlen Ir peetlen By D.t. C.mme W Dmc p.�o k 507!• /�ha.� 7.6 lho. (,0357 L� k5f 48 &12ei !h g&L" as'ajtk ACCOUNTING ONLY: AID/ I FACT PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE P9YYIITISp CE REQUEST NUMBER INVOICE I