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APPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SEI :S ENVIRONMENTAL HEALTH DIVISION R0. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 1209 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1C9mplete 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 16 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN# -,ICA( ([/c, ��'Ylpr�I— >% CITY fir c<noN PARCEL SIZE/APNI nn nn ;�9ie)yvy. OWNER'S NAME l�'�JC i Yq(� CR_Oq/-'L ADDRESS 60 13 I S!j^ryy l q� PHONE CONTRACTOR S („/ �21 !N�r J ADDRESS_ /"p d-$,< 5-( l't/D�//Si/4 UCi 7" /� PHONE -73 7S- SUB CONTRACTOR ADDRESS UGI PHONE. TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL RrMONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL 11New 13Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL �- p (TYPE OF PUMP) � ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS// A ❑ INDUSTRIAL �❑OOPEN BOTTOM DIA.OF WELL EXCAVATION a DIA.OF CONDUCTOR CASING /t//x p ❑ DOMESTIC/PRIVATE IJ GRAVEL PACK/SIZES _S/JJL) TYPE OF CASING/STEEL/PVC �.2 r( ?YCZ- DIA.OF WELL CASING .2 ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL L Z S / SPECIFICATION ,9'f/HJ R ❑ Ir RRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY —IA/C LIR GROUT BRAND NAME 7 f LLJ MONITORING GROUT SEAL PUMPED: B Yea [IN. CONCRETE PEDESTAL BY DRILLER:Erly. ❑No S APPROX.DEPTH ! S LOCKING CHESTER BOX/STOVE PIP£ S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER ly, CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAGUIN 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 i THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY T T IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE PPU NT T C 2479 IN ADVANCE FOR ALL REQUIRED INSPECTION"S�AT 1209)4893422. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slpned X G/ in L Title 2�/AAX /1/T!,-r ,/� /t(/S� Date & ` G / PLOT PLAN(Drswv to Scale)Scale_'to�_ :1 1. NA SOF STREETS OR ROADS NEAFI�ST 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 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. ' ll PRD(�SClD Mt.JNDS( S/bC oF7SreEZ? W. Ft?tmoA S' T AIVRW301MAT14 pr L.aG4TtoN SHcxJ•� M w 5 flG l n' O wK AMOK. UX^ _ N l 40 . ..._ O new 2 0 &'XISI44*- HAorO tTb¢I-)�r LL PRoPOS4Z4.....MDn),,C2A..file (w?/ld /. .. _ SToc,Ict0,1 tM4J2 i� '7 /7 DEPARTMENVUSE ONLY ) / Appllcetlen Accepted By Date `� Area Grout Irnpectlon By Date Pump Inspection By Date Destruction Inspection By Date Comments: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED HEC RECEIVED BY DATE PERMITISEAVICE REQUEST NUMBER INVOICE 'J�