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APPLICATION FOR WELLIPUMP PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SERVI 4 ENVIRONMENTAL HEALTH DIVISION PAYMENT P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 RE E1 (2os� ase3a2o �—oN. r' � �jj ? SAN f0, )UIN CC!INTY [ S NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM PATE ISSUED ' � (Compkts in Tripikats) �n PUBLIC HEALTH SF7YEffR•��VIIC��ttrE1CCS�Irtn�n�i APPLICATION IS HEREBY ADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED, SAN JOAQUIN COUNTY DEVEL ENT TITLE,CHAPTER 9-1115.3 AND THE STAN A D OF S JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. "� ^ter '196^f[DC}RBsroR N om{ 2-10' O R CITY �OV t _PARCELrSIZEIAPNX5iO(04+ 7L GeAS OWNER'S NAME \H'1 ASB. `J� '� fes, G Rf ADDRESS qc.r { �j P I: ru- C7r pl{ONE ' ` 7 7-/,%n CONTRACTOR 1<LI,I 1�V�,{�=G�� I I� - _ADDrR�ESSSL _1°�,,�'Cj . M y�'R-LyyG y ��'j PHONE�� SUB CONTRACTOR FYw�I �+ + ADDRESS W11 VAM ai "q,Sp�• CN �`� PHONE s Z TYPE OF WELJUPUMP: NEW WELL ❑ REPLACEMENT WELL ONITORING WELL/ SI f ❑ OTHER N ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLr J 112C ❑New❑P.Palr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL Q ITYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL M ❑ SOIL BORING I 6 ❑DESTRUCTION: ` INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS J•�j� y� A 11 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION Or DIA,OF CONDUCTOR CASING /T- D I� ❑ DOMESTICIPRIVATE RAVEL PACKlSIZE V �LO TYPE OF CASINGISTEEIJPVVCey �' DIA.OF WELL CASING 7�f D ❑ PUBLICIMUNICIPAL L❑DRIVEN DEPTH OF GROUT SEAL S-_r/ (P 4 � SPECIFICATION R v ❑-t IRRIGATION/AG ❑OTHER 7 GROUT SEAL INSTALLED BY re11MM C+ GROUT BRAND NAME E SXMONITORING �y I GROUT SEAL PUMPED: Yee ❑No CONCRETE PEDESTAL BY DRILLER:❑Yw ❑Na $' X.DEPTH FIFIET LOCKING CHESTER BOXISTOVE PIPE�L S, PROPOSED CONSTRUCTIONIDRILUNQ METHOD: MUD RtOTARY AIR ROTARY AUGER^ CABLE ' OTHER ` I HEREBY CERTIFY THAT 1 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 FOR WHICH , THIS PERMIT I ED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES i THE FOLLPWAT THAT THE PERFORM CE OF THE WORK FOR WHICH THIS PEFiMR IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'6 COMPENSATION LAWS Of CALIFORNIC NT M 24 HG ADVANCE FOR ALL REQUIRED INSPECTIONS AT(200)468,3423. COMPLETE DRAWING ATLOWERAREA PROVIDED. +I Signed X r Title J �L Vy / _ Dete 1' t I I PLOT PLAN [Drew to Scale)Scale 'to 1 F. NAMES OF STREETS O ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PRiOPOSED S I 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. i 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING C1 VERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. - � .... ,.. . :.:. F. >� .. .. ... _. .. �z. .. 4 iP /J DEPARTMENT USE ONLY Application Accepted By Date / L p Area Grout Impaction By D.1.*1 Pump Inspection By' Date Dmtruction inspection By I �� Date Comments: c7v 4 .' I{ �I jjI ACCOUNTING ONLY: AID# II FAC# n f I>r PE CODES FEE INFO AMOUNT REMITTED r CHECKO/CASH RECEIVED BY DATE PERMITISERVICE REGDEST'NUMSER INVOICE 220 /LGu� o � L5726 06 2F,5-5