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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERI. ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 4683420 NONREFUNDABLE PERMIT 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 MTH SAN JOAQUIN COUNTY DEVELOPMENT TRUE,CHAPTER 9-1116.3 AND THE STANDARDS OF SAN JOAQUIN COUNFY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH OMMON. JOB ADDRESSIOR APNI CRY PARCEL SIZEJAPHI OWNER'S NAME ADDRESS PRONE I CONTRACTOR ADDRESS LICE PHONE I SUB CONTRACTOR ADDRESS ME PHONE I TYPE OF WELIJPIMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS{ONNECT REPAIR ❑ VAPOR EXTRACTION WELL P ❑Nw❑RaoNr M.P. RYP OF PUMP DEPTH PUPMSET FT. FIRST WATER LEVEL D ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL/ ❑ SOB.BORING 8 ❑DESTRUCTION INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGh EELPVC DIA.OF WELL CASING D ❑ RIBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFIOATION A ❑ IRRIGATIONIM ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITONNG GROUT SEAL PIMPED: ❑Y— [IN. CONCRETE PEDESTAL BY DRLLEB,❑Y. ❑Ne S APMOX.DEPTH LOCKING CHESTER 90Xt0TOVE RPE S MOMSED CONSTRUCTIONIDNWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPUCATION AND THAT THE WOR(WILL BE DONE IN ACCORDANCE WITH SAN JOAOUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SMI JOAOUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMIENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS 196UED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATON LAWS OF CALIFORNIA.' THE APPLICANT MAST CALL N HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONA AT 12(HR SSf-SS31. COMPUTE DRAWING AT LOWER AREA PROVIDED. SIOM X T10E DAb KOT PLAN I .IP SPAIEI tieAlA to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. A. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROMSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISROSAL SYSTEMS. ]. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PRDRDSFQ 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. MAP ON BACK I DEPARTMENT USE ONLY Apellotllen AeeaplW By DRE AIr. Greve Impectlen By DSte wno Impectlon By DKP DrOuetlen Irrestbn BY DAta Cemmenu' ACCOUNTNG ONLY: MDI FACT PE COD" FEE INFO AMOUNT REMITTED CHEC"XASH RECEIVED BY DATE KFINBTISERVICE REQUEST NUMBER INVOICE