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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 (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 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. /587 fi"InA (!ne rur npyee 57"blickli JOB ADDRESS/OR APN# �rMell P14),P14),/Q CITY 60X 8� PARCEL SIZE/APNN �/ L -Y VV/II-13' 7 1 OWNER'S NAME .. PE CODES FEE INFO AMOUNT REMITTED ADDRESS ji PHONE #_ 1M1'S CONTRACTOR Y r UI IrI'/` �L ADDRESS fa & X 37 &O V;s ra LIC.110,418 PHONE # JC�^�✓ �r- S/'Y' SUB CONTRACTOR W- � .J' qyV "• ADDRESS/��7 d17 ��I7� M�errwlf UC#a�.J�Q PHONE #Il"y-7175 ��v ' TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ® MONITORING WELL # 1, � 7 MOTHER )re -1A ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS -CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # J ❑ New ❑ Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) y ❑OUT-OF/-SERV/ICE/WELL / GEOPHYSICAL WELL SOIL BORING 09 DESTRUCTION: Ae-s.�wr /r-w-te,J W7/P11bWQnOeCmC,1/1 /11W — B /.� INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA. OF WELL EXCAVATION s DIA. OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC �V L 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 5-.0 ^ r GROUT SEAL PUMPED: ❑ Yea ❑ No CONCRETE PEDESTAL BY DRILL FR: ❑ Ys [IN. S APPROX. DEPTH J 0-I ee LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY Alt ROTARY AUGER CABLE OTHER /t Lr-U.;r X7:16' �l'CirrinrF' ,�� Wf fart/a it s' c'C'/l7P.�t1 /P p�C +�ti1(161Af e CQ�J I 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 RULE 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'S COMPENSATION LAWS OF CALIFORNIA. - i APPLICyANT MWST�CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091 4693423. COMPLETE DRAWING AT LOWER AREA PFjO VIDED. Signed X �(,(;' /�t,y _ Title, Date PLOT PLAN (Draw to Scale) 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 6. 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. (T11 rr N I ' , , I ' if AVP13Alae NiNn3GIS I Atl%3AINg I a *MW -2 EXISTING MONITORING WELL i A5e-2 ANGLE SOIL BORING LOCATION ANO DIRECTION e JP Joint Pola-Overhand Power linea ■ OL D,6,, Inlet '•"'? ----- Groundwater Elevotian Contour DEPARTMENT USE ONLY ^ Application Accepted By ' ` Date ! Ars Grout Impaction By Date Pump Inapectlon By / Data Dstruction Impaction I tM '7- j "T ACCOUNTING ONLY: Al.. PE CODES FEE INFO AMOUNT REMITTED CHEC IC ASH RECEIVED BY DATE I PERMIT/SERVICE REQUEST NUMBER INVOICE '-� 3