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SSAPPLIC!,TIQf�FIR WELLIPUMP PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SER ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9%01-M (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' o' (Complete In Triplicate) 30 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 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN# q1,10 rf—eOI✓IJi Ii tl- -3,4—6 70 -(%L CITY /,�+}/[y PARCEL SIZE/APN# OWNER'S NAME i Y e'1•J -L/n/ FI ADDRESS L�^1/.. r- C � //i`iCC�L1,9 �YJPHONE CONTRACTOR ADDRESS ,/ / a- LIC# PHONE# SUS CONTRACTOR r,'L!°/`+,,,J<�9��Yll'L/ti'G Ivy ADDRESS-4l Ct�C//SC- �/-+r+'�aC�JC#(��'.�iF`� PHONEA115)145C-;`-'rj'7 TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# (TYPE OF PUMP) 11New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# CJ SOIL BORING 7�C _ iL /�•-au-vcS B ❑DESTRUCTION: (/�` INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING 0 ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING 0 ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION q ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER:[1Y.. ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY 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 JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE R1�ANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.'JE CANT MUST CALL 4 8 IN ADVANCE FOR ALL REQUIRED iNSP T10N8 AT(208)4883423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X Title Date PLOT PLAN IDraw to Seale)Scale '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 INCI unING COVFRFn ARFAS 911CH AS PATIOS nRiVFWAVS Ar,1n WAI VC nN THc 0wnM9rrV nR An tnlAulun D nCWr ........ ,p....::......:............c......:............... ... .. ......:.............%......... .i.. . ;. .. -_. .. .. DEPARTMENT USE ONLY Application Accepted By Date Grout Inspection By Date Pump Inspection By Date Destructlon Inspection By - Da / >~ ti'�rrl°# tiv�n •fir Comment : s CATs = -- ^-euaswre: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE