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APPLICATION FOR WELLIPUMP PERMIT ;I JOAOUIN COUNTY PUBLIC HEALTH SERYIC - i A--� -- ENVIRONMENTAL HEALTH DIVISION ;6Lf P 0 BOX 388, 446 N. SAN JOAaum ST, STOCXTON, CA 96201.388 (2091468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM, DATE ISSUED `-, ICaanpMts is Tripliaaa) 11 Application is here by made to the San Joaquin County fora made in compliance with San Joaquiny pment Title, chapterit to c9-1115.3 andonstruct /the 'Standards of San Joaquin work d•County This aPublictN alth Services; Environmental Health Diiiion t Develo Job Address/or APN# �J S Q III�i _ City Parcel Size/APN# Owner's Name .% ! AddressBmaM, I?M. � u-1110Lt Phone # - ppp contractor�Q[, . �H►I•'Ztg_�„��'* Address W7 O��} "�' CLs# Phone #(71tOYVa-77dp Sub Contractor_ $+ (�e Dr;(lLvlf5` Address F 1 Sqt lic# 97 9 Phone #lg16163e•)27(s ip r TYPE OF WELL/PUMP: U NEW WELL U REPLACEMENT WELL ,g DESTRUCTION 11 OUT -OF -SERVICE WELL J k U MONITORING WELL # U GEOPHYSICAJ WELL #1 U OTHER U SOIL BORING 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 perf nce the work for which this permit is issued, I shallnot employ persons subject to-WORKNAN'S COMPENSATION Laws of Cali forni Contractor's hiring or sub -contracting signature certifies .the folillowing: 111 certify that in the performance of the work f which this permit i ued, Itall employ persons subject to WORKMAN'S COMPENSATION laws of California.” THE APPLICANT MUST CALL HOURS ADVANCE FOR A L R WRE NSPECTIONS AT 120114111-3423. Complete ldrawing! at lower area provided. f SiTitle ��) (c , ()ate �S� 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 2. Outline of the property, giving dimensions and North direction. ;G pr4msed expansion of sewage disposal systems. 3. Dimensioned outlines and location of aLL existing and proposed 1,5. Location of wells within radius of 150 ft. on structures, including covered areas such as patios, driveways, 11, the property or adjoining property. -4 u.i4c 1, SEE r b M RTMENT USE ONLY Application Accepted By_ Grout Inspection By Daa a Pump Ins Destruction Inspection By Date J Conments:11 I' By Date I ACCOUNTING ONLY:AiOAt U INSTALLATION U WELL SYSTEM REPAIR U CROSS -CONNECT REPAIR U VAPOR EXTRACTION WELL # PE CODES FEE INFO AMOUNT REMITTED 11 New U Repair H.P. DEPTH PUMP SET'� FT. FIRST WATER LEVEL (TYPE OF PUMP) INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS U INDUSTRIAL U OPEN BOTTOM DIA. OF WELL EXCAVATION i �# DIA. OF CONDUCTOR CASING U DOMESTIC/PRIVATE U GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC Ik DCA. OF WELL CASING U PUBLIC/MUNICIPAL U DRIVEN DEPTH OF GROUT SEAL It SPECIFICATION II IRRIGATION/AG 11 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME U MONITORING GROUT SEAL PUMPED: U Yes U No CONCRETE PEDESTAL BY DRILLER: U Yes [) No APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE 11 :PROPOSED CONSTRUCTIONIDRILUNG 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 perf nce the work for which this permit is issued, I shallnot employ persons subject to-WORKNAN'S COMPENSATION Laws of Cali forni Contractor's hiring or sub -contracting signature certifies .the folillowing: 111 certify that in the performance of the work f which this permit i ued, Itall employ persons subject to WORKMAN'S COMPENSATION laws of California.” THE APPLICANT MUST CALL HOURS ADVANCE FOR A L R WRE NSPECTIONS AT 120114111-3423. Complete ldrawing! at lower area provided. f SiTitle ��) (c , ()ate �S� 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 2. Outline of the property, giving dimensions and North direction. ;G pr4msed expansion of sewage disposal systems. 3. Dimensioned outlines and location of aLL existing and proposed 1,5. Location of wells within radius of 150 ft. on structures, including covered areas such as patios, driveways, 11, the property or adjoining property. -4 u.i4c 1, SEE r b M RTMENT USE ONLY Application Accepted By_ Grout Inspection By Daa a Pump Ins Destruction Inspection By Date J Conments:11 I' By Date I ACCOUNTING ONLY:AiOAt FAC# I� PE CODES FEE INFO AMOUNT REMITTED CHECKACASH RECEIVED BY DATE Ij PERMIrISERVICE REQUEST NUMBER INVOICE �s 0 a-- 1�rL� S 23 S r �} it