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,~ APPLICATION FOR WELLIPUMP PERM' w,u/ SAN JOAQUIN COUNTY PUBLIC HEALTH SEIIT�'ES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 988, %X EAST WEBER AVENUE, STOCKTON, CA 55201.388 (209) 469-3420 NDN-REFUNDABLE PERMIT EXPIRES 1 YEAH FROIA DATE ISSUED (Compkto In Triplicalml APPLICATION 19 IIERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOW DESCRIBED.THIS APPLICATION IB MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,C`HAPTER B-1 116.3 AND THE STANDARDS Of BAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR AA,P,R! I_ -1 1 ` M, TfQ,��fya . CITY –rcne- - PARCEL SIZFJAPNP OWNEW9 NAME FhI R {VLce . �` ��IAR�-,... ., ADORESS � IOS{,g TrI�� ,r�q.53"Lh PHONE/ CONTRACTOR EIsr– �IItV I JSZSAI FNCJJ `__.,_, ADDRESS "1 C S Llc#r.�T4�5c3 Sr6S PHONE, CotLbu-n++s eeNPMe�oR ikkir /T_ -d Z r-O J I�rOy _ uT•.._ ADDRESSl .A]S 6k3 L1CN PHONE fT�yq-�]� 1324> TYPE OF WELLlPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# j (TYPE OF PIIMPI D New 13Repolr H•P, DEPTH PUMP SET FT. FIRST WATER LEVEL O 11OUT-OF-BERVtCE WELL ❑ GEOPHYSICAL WELL# BOIL BORIN S 3 B ❑DESTRUCTION: INTENDED USE TYPE OF W CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION Z I DIA.OF CONDUCTOR CASINO D ❑ DOMESTICIPRIVATE ©GRAVEL PACK/SIZE TYPE OF CASINGISTEELtPVC DIA.OF WELL CASINO D ❑ PUBLtCIMUN1CWAL ❑DRIVEN DEPTH OF GROUT SEAL_ - I SPECIFICATION R ❑ IRRIGATIONIAG Ll OTHER GROUT SEAL INSTALLED 9YdrjjjCC GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Y. [IN. CONCRETE PEDESTAL BY DRILLER:❑YM ❑Ne S APPROX.DEPTH__ _ 15 get— LOCKING CHESTER BOXISTOVE PIPE - S PROPOSED CONST'RUCTTONIDWWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER�LVyS� 1 Hf'RESY CERTIFY THAT 114AVE PREPARED THIS APPLICATION AND THAT THE WORK WILL Be DONE IN ACCORDANCE WITH AN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULER AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S BIONATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1814ALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 ERT HAT IN THE PERFORMANCE OF HE WORK FOR WHICH T1418 PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF NIA. CAlfFDR ' t ANT ST CALL 24 fROUR/ VANCE FOR ALL REQUIRED INSPECTIONS At 12041409-5422, COMPLETE ORAWINO AT LOWER AREA PROVIDED. Btpnsd X Tid. l � One PLOT PLAN(Drew to Seale)Beet. "to 1. NAMES OF STREM OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE INSPOM SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. I. 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. se b. DEPARTMENT USE ONLY f Appllcollen Accepted By CalDat. 7 �r At" d7 5-& Grout Impaction By Dote Aanp Impectlon By Date De.tnretlen Impxttan By Dote Commaee: ACCOUNTING ONLY: AID# FACT PE CODES FEE INPO AMOUNT REMITTED ECK NCASIT RECOVED BY DATE PERMIT11ERVICE REQUEST NUMBER INVOICE Pub.HeaRh Serv.-Enviro.173(3196)