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APPLICATION FOR WELLIPUMp PERMIT, SAN JOAOUIN COUNTY P F r `~ PUBLIC HEALTH SEES ENVIRONMENTAL HEALTH DIVISION � P.O, BOX 388, 304 EAST WESER AVENUE, STOCKTON, CA 9520��8$ I (209) 488.3420 I� ; NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED APPLICJOAQUIN ON N HERE EL MADE TO.THE SAN JDAQUIN COUNTY FOR A PERMIT TO CONSTRUCT IAND ORI INSTALLI THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1119.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. 9 I JOB ADDRESSOR APNr ( oq 0 Nafl d l i �{ CITY L-^0 OWNER'S NAME a irO J`1 t /t PARCEL SIZE/APNIF �ahfnl]4R�T tt)t r ADDRESS j tja g 0 n�,_ r !`YIP PHONE raj I 41a►r�RAe>felR lrosce eD FI►L�iNO IIM1+N�' 1 L, ` AdDRE88C�j szl( uc�^PHONEr S6' e4lB caNTRACTOR Cd 5 Cud[ Dri j1)1A ADDRESS II�Jr'O ,r'►1 ion t IV t 7I F 0 &' TYPE OF WELU/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ,' ❑ OTHER l ❑ CR088-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r r 13 New❑Repels H.P. � J , (TYPE OF PUMP) DEPTH PUMP SET FT. FIRST WATER LEVEL ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELLf O la, SOIL BORING (O t 8 ❑DESTRUCTION: INTENDED USE TYPE OF WELL �� ij ❑ INDUSTRIAL PE BOTTpM CONSTRUCTION SPECIFICATIONS if A DIA.OF WELL EXCAVATION I. ' DIA.OF CONDUCTOR CASING_ ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELlPVC �" I jI D t {-y GIA.OF WELL CASINO '�" D ❑ PUBLIClMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL 10 4 -V tj UN :+ SPECIFICATION ❑ IRRIGATKINIAG ❑OTHER I R GROUT SEAL INSTALLED BV II! GROUT BRAND NAME h lax LlIVI a 1 E ❑RMONITORING DEPT GROUT SEAL PUMPED: ❑Yea ❑Ne I 0 CONCRETE PEDESTAL BY DRILLER:❑Yae ©No 'S } APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE } (� S PROPOSED CONSTRUCTIONIOPoLIJNG METHOD: MUD ROTARY AER ROTARY AUGER I- Ih CABLE OTHER Dt1"4 G l F IUS I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE 61 ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCE8,STATE LAWS,AND RULES AND ' REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING;•f CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH I F THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN-6 COMPENSATION LAWS OF CALFFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLLI�C/�A�NT�MUST �CALLL 124 HOURS IN ADVANCE FOR ALL REGUNRED INSPECTIONS AT t20414SfJ42a, COMPLETE DRAWING AT LOWER AREA PROVIDED. . "KJ"'�WV"PV u e[[[ Signed X Tkfe data n4j. PLOT PIAN(Draw to Basle!Scala 'to I� I. NAMES OF STREETS OR ROAbB NEAREST TO OR BQUNOING THE PROPERTY. t 4. LOCATION OF HOUSE SEWAGE DISPOSAL 6Y8TEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINFS 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. r � ... - .Z -.'� ....k I i . . ...... _ . ... ..l... ..��. .. .. s . ! I ..,... .. ....L. : .. ........ . ... _ . ... ...... . - i s it I .......... .r . .. . . I� i I ' ..� DEPARTMENT USE ONLY h ,I Applltstlon Accepted By V II Dete Ara i Grout Inspection Bybk& ate Pump Inspection By I. i Date Destruction Inspection By .I � Date I Comments. ' ACCOUNTING ONLY: Atilt FACT I � PE CODES FEE INFO AMOUNT REMITTED CHECKrICASH RECEIVED BY DATE II PERMIT/SERVICE REQUEST NUMBER INVOICE a