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APPLICATION FOR WELLIPUMP PERMIT v SAN JOAQUIN COUNTY PUBLIC HEALTH SERr.iIkS ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA VM1388 (209) 469-3420 NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete In Tripfiieatn) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPUCATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER,H-1115. AND THE `STAND I,DS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB AbbRE88roR APN# l CI LST f u;�'� :'7� /S��v�. cm y�f c C>; CA �/ ( �j PARCEL SIZEIAPN# OWNER'S ME �r �Wrt; l I✓:JI'L tTV �"t ADDRESS T`�t ✓ , S��'` 1' Z" 5—Z3�� '}!� /q PHONE# Y ` CBTPFEMIGSOEF- !1 1�1I c f�1 Cc( C. ADDRESS `' '•j{" - LIC/ /V b{ O d PHONE! -53 T l-/13 1r�/0.? MO CONTRACTOR O Od k'CV ADDRESS °�� JKfj UG/ S-�_PHO NE I TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL if J RYF'E OF PUMP) [3New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O G OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# lEr SOIL BORING Z e ❑DESTRUCTION; INTENDED USE TYPE OF WELL CONSTRUCT116N SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION U DIA.OF CONDUCTOR CASINO p ❑ DOMESTMIPR IVATE ❑GRAVEL PACKISIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ RI iiRGATIGN/AG 11OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E wmONRORING GROUT SEAL PUMPED; ❑Yr ❑No CONCRETE PEDESTAL BY DRILLER:❑Yw [IN. S APPROX.DEPTH LOCKING CHESTER BOXMTOVE PIPE S PROPOSED CONSTRUCTIONIDRILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE9EBY CERTIFY THAT 1 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 AQUIN 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,1 SH NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: I ERT THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORIQNAN'S COMPENSATION LAWS OF CALIFORNIA.' T C T MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED II�NSPECTIONJ$"/T 1.2�0�[�lg1.,4g342'. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X Title — _ Dote PLOT PLAN 10rew to Scale)Scab to 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 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. I _- -.-: -._.. -..._...- .. -, .................... ..........;.... ...-.,..:.. I DEPARTMENT USE ONLY Appllcation Accepted By t Dote 1 A, q / Grout Irnpeelion By Date Pump Inspection By Data yspeatruetlon Inspection By Date Comments: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECCK#/CASH RECEIVED BY DATE a PERMITIISEERVIC'EE REQUEST NUMBER INVOICE V , 1,q� L V V CJS