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APPLICATION FOR WELLIPUMP PERMIT U ;AN JOAQUIN COUNTY PUBLIC HEALTH SERV;, ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201-388 (209) 466.3420 it NON-REFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSUED (Complete in Triplicate) .1 APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION 15 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TIT CHAPTER�9--'11 1 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PPUBLIC HE/A�L®TJI SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# Q �d/ t: CITY PARCEL PA ELSIZ PN OWNER'S NAME e ADDRESS I # Z CONTRACT4 M ADDRESS I LIC# k1k PHONE# i SUBCONTRACTOR D LIC# ii. dl TYPE OF WEWPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ 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 PUMPI ❑ OUT-OF-SERVICE WELL ❑ G OPHY ICAL WELL# ❑ SOIL BORING B DESTRUCTION: L INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS ,q ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKlSIZE TYPE OF CASINGISTEEUPVC DIA,OF WELL CASING p ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 'SPECIFICATION R h ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONrrORING GROUT SEAL PUMPED: ❑Yee ❑Na CONCRETE PEDESTAL BY DRILLER:❑Yee ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE FII S PROPOSED CONSTRUCTION/DRILIJNG METHOD: MUD ROTARY AIR ROTARY AUGER , GABLE OTHER 31 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:M 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 IP3,TME PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS O3 i CALIFORNIA." TH APPIIJ A 24 ADVANCE FOR ALL REQUIRW INSPBCTION6 AT i2oel 466.5428, CQMNZM DRAWING AT LOWER AREA PROVIDED. - Signed X TIO Date MAT PLAN IDraw to Staley Sole to4� 1. NAMES O BEETS OR ROA 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. it ON THE PROPERTY OR ADJOINING PROPERTY. .. _. <... ....,... .... .. .L. .,.-,.. ..,:... .I._. -._ ................ .. - ' - - ....,..:. _._.. . . .. ........... . .. . .. _. .. . . - . . 1 . A. w-3 - . DEPARTMENT USE ONLY /'/}Application Accepted By 5 ' ! C J 5© h/ i� r Date Aree Grout Inspection BY Date I,•_i,[O Pump Inspection By Date Destruction inspection B ,F Y +v t Date Comments: ACCOUNTING ONLY: AID# FAC# I'1 PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PEYNITI513mcr.REQUEST NUMBER INVOICE 3542 5r - nab 2 I