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• APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER t99--111 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY(Y PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. KID v C�%N+4� �/�CL L-^ CITY �J� r r��✓ PARCEL SIZE/APNN _ JOB ADDRESS/OR Av�lPNN# ji �r /_T J, X76, gs rp RE.-Sr E/L 2Lw OWNER'S NAME MIR n! ^AAITI/V ADDRESS `']CJRN �1ja 51i yq t9-r�'2� PHONE E / f CONTRACTOR V 1 S I I�!7 Z MA!7 ADDRESS � B—=PCO•"KD L�Ag SONE N a ADDRESS LIC# PHONEN SUB CONTRACTOR TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL X ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ✓ ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL fl.•�� (TYPE OF PUMP) t❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# SOIL BORING ��/��` ^ F 90/1—g DESTRUCTION: �.-�' �� :Yzy0 A INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O ❑ INDUSTRIAL ❑OPEN BOTTOM D TYPE OF CASING/STEEUPVC DIA.OF WELL CASING ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE � ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION ❑ IRRIGATION/AG El OTHER GROUT SEAL INSTALLED RY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL i'UPAPED: ❑yes ❑No CONCRETE PEDESTAL BY DRILLFR:❑Yea [IN. S S LOCKING CHESTER BOX/STOVE PIPE APPROX.DEPTH PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 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:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 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 IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THE APPLICANT MUST CA 24 HOURS IN ADVANCE FOR ALL REQUIRED INSiEC IONS AT 1209)4eb34223. COMPLETE DRAWING AT LOWER AREA PROVIDED. _ it , /l i"A��. rf� "t � C`-�i: Cr' , <- Date f,7 ��,��-s Signed X' s C lits - - Title PLOT PLAN(Draw to Scale)Scale_"to 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED I- NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED ON THE PROPERTY OR ADJOINING PROPERTY. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. .. . ... ... ... .... ... . .. m .:. ..:.... .:..... .....:. �O ............® �.. ...�..... . ....... : ... ........... . . . :. . : .. . ...: . .... �. r . I ............................ . . .�.q tit, . .C.>../.�i..4�............,......,.......,.............,......;.............. �. .. ' �1,Q........:.......>.........................<.......i.......;............ Y' ..... . . . . ............. . ......:......>......:.....;:.............>..... ....... ►. ............................:.. ... . . ..... .:.. .. .:......:.. . ...;......:.......;......:...... .. . .. ..... .......... JA ° ilbrg .. .. DEPARTMEIMT USE ONLY L� Dete - `/ Area Application Accepted By Grout impaction By Date Pump Inspection By Date �'✓/7 /�i S' Date Destruction impaction By l Comments. ACCOUNTING ONLY: AID# FAC#' PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BV DAT PERMIT/SERVICE REQUEST NUMBER INVOICE