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1w/ APPLICATION FOR WELLIPUMP PERMIT, , SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P O BOX 388, 446 N. SAN JOAQUIN ST.,STOCKTON,CA 96201.388. (209)468-3420 ;= NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE"ISED (Complete in Triplicate) APPLICATION N HERE E MADE TO THE SAN JOAQUIN COUNTY FOR q PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,All, J.111 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. v) ^ JOB ADDRESS/OR APN# f 00 All,t S, �f��- � �,.�/0 v Cn.y S�� d/) PARCEL SIZE/APNN < 6/A /�f// OWNER'S NAME \ S /t C ADDRESS 7 / "��r st i Cd O CoN P)6/3`2 717 CONTRACTOR t i� �A I (.CC 1 ADDRESS Z7(J(./l7 .ILS A 'lino PHONE �7-z!7i SUB CONTRACTOR_5 lM F`5IAL� A%f ADDRESs23(� t S�. 7 ' PHONE# 7J7 TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL ter ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLY J ❑New❑Repair H.P. DEPTH PUMP SEP FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL Y ❑ SOIL BORING g DESTRUCTION: f 14S, LGN-+� l7�(.I t (�✓j�.'/ `� -/I Gbt �iL'�LC.I.d.�! /��al�A�t Y�4 {•'V �I��' �/ �A //�![ ,t INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUIPVC DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLFR:❑Ys [IN. S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 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 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 WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA//./�'-yyTH��E�P�ICAN`T MUST FALL 2 fHOU IN ADVANCE FOR ALL REQUITitlRED INSPECT ION$AT 120 14683423. COMPLETE DRAWING AT LOWER AREA PROVI D. Slpned X "'7 V! "/TGA /l'7ra V!/lV Date PLOT PLAN IDraw to Seale)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 5. 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. ............ ....... ..:....:....:............: ........ ....... ....... .............:................. .....;.......:....................:............:........... w �...... ..... t ' .� r ..... / �✓� , C GtJ 3 . '1 G/ 5,...1 ✓C. ...... r .. :.......:......:.......:......:...........................:...................... .. ...... ... ..... .: ��..�.?., ..... ... ..... ...... ...........: .. .....................1...... ...................... .a� . .... ...... .. �� f/s...............free: . � ..... ... ......... ............. ............ ..... ........................ ............................ .:............:.. ..: . DEPARTMENT USE ONLY Application Accepted BY D. Area Grout Inspection By Date Pump inspection By Date Destruction Inspection By Date Comments: ACCOUNTING ONLY: AID# FAC# / PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE b Gl`? 00 0