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�t APPLICATION FOR WELL)PUMP PERMIT SAN JOAO.UIN COUNTY PUBLIC HEALTH SERVICES & ENVIRONMENTAL HEALTH DIVISION r-= P 0 BOX 388, 445 N. SAN JOAOUIN ST., STOCKTON, CA 55201.388 (209) 468-3420 40 REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED LL) , kc incl- IC&mpl&t&in Triplintal APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR 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 COUNT_Y/PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS,.,AP,INM .4149!S� ��L�� f4( �4e 1jl'' CITY�! /7�'-t- PARCEL SIZEIAPNN OWNER'SNAME �^dsT �s4L }�A/ ADDRESS _RiONEaR /�Q}^p�`Lpy��7p�J9 CONTRACTOR No/I1`�c'J /S�O .4F.P a/w11 _ ADDRESS4 p • r/�'E O'—r LIcN p�&71 PHONE 0 !T r' O-Po/7 s`�'ric Ta.� SUB CONTRACTOR ADDRESS LIC, PHONE N TYPE OF WELUPUMP: ❑ NEW WELL 'I❑ REPLACEMENT WELL ❑ MONRTORING WELL! ❑ OTHER ❑ INSTALLATION qy_WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J IXN.❑Rapalr H.P. , V DEPTH PUMP SET 40 FT. FIRST WATER LEVEL Q O (TYPE OF PUMPI r rPx-te pr OUT-OF-SERVICE WELL ❑ GEOPHYSICAL.WELL N 13 SOIL BORING B (3 l DESTRUCTION.. INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A L ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.Of WELL EXCAVATION , DIA.OF CONDUCTOR CASING O 13DOMESTICIPRIVATE [3 GRAVEL GRAVEL PACK,SIZE TYPE OF CASING/STEEIJPVC Py 4 DIA.OF WELL CASING D PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL / S P SPECIFICATION A d ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME L�.rv,U �fl� 'P E C ❑ MONITORING h f GROUT SEAL PUMPED: ❑Yes [IN. CONCRETE PEDESTAL BY DRILLER:❑Yee ❑No S a APPROX.DEPTH �(� LOCKING CHESTER BOXISTOVE PIPE S [� PROPOSED CONSTRUCTIONIDRILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 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 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." THE APPLICANT MUST CARL 24 NOl6i&I-N`-yAD///yANCE FOR ALL REQUIRED INSPECTIONS AT 120!&1 4&&4429. COMPLETE DRAWING AT LOWER AREA PROVIDED. signed x'.�_� '!9/� fY�•� � Title G `^ L3/� L- �I �R/E/� Date PLOT PLAN i0rex to Scale)Scale 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, .. ....,., l N �TSF c t_ /✓G4� .-c ..... :.. 1! . .. ; _ ... ... iii i LAG L_0. 1�17a Z? Cv v.C'wy .. �.;. ..A ;,elle .G� %f' . . ... �? I 1 I lsi _ I.......L � 7 .. .,. x� cu R PPR-0y- ...:....... � ;..... X12 r 'I L ... . � .. ..... ...; . Al a u .. 1A0. r ,. r ........ . ,1.�7 N 1..6 . . r y1�1 1Ur,l mil. .t,Vu . Y L., - PUBLIC HEALTH;SERVICES ; ENV 1110NME. NTAL HEALTH DIVISION 11211 ........ ..... ..M. ..... DEPARTMENT USE ONLY Application Accepted By Dot* I Ares l� f J Grout Impaction By I _Pump Irnpeutlon By _ Dete Dstr—tion I—peetlon By Det* r Commerde• �~ ACCOUNTING ONLY: AID# FACN 7 PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE T49IVICE REGU T NUMBER .VOICE