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APPLICATIO FOR-WELLIPUMP PERMIT --SAN JOAQUIN COUNTY PUBLIC HEALTH SE81r._._.ES $ ENVIRONMENTAL HEALTH DIVISION T ` P.O. BOX 388, 344 EAST WEBER AVENUE, STOCKTON.CA 35241388 (209) 468.3420. _ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ._ s ICBmpfeta in Trip3ieab) 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 TIT/u,,CHAPTER J9-1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH-SERVICES,ENVIRONMENTAL HEALTH DIVISION. /� JOB ADDRESSIOR APN/ '�V%`0/1 CITY PARCEL SIZEIAPNlI7+"/�O OLJ�J~02- OWNER'S NAME i ADORES !/tyC,I �,,LlI - fJ� f J/ PHON� `?pi�pr-/y1V CONTRACTOR ADDRESW��4Lii�,rcI W Lf[(j L3CrC57�833IQNE SUB CONTRACTOR ADDRESS LIC! PHONE# TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL* ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑N.❑Rapalr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL (TYPE OF PUMP) n'A ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING g DESTRUCTION: !/� r INTENDED USE TYPE OF W1A CONSTRUCTION SPECIFICATIONS A � ❑ INDUSTRIAL ❑OPEN-BOTTOM DIA.OF WELL EXCAVATION �7jS'//DRi DIA.OF CONDUCTOR CASING � D ❑ DOMESTlClPRIVATE` GRAVEL PACK18lZE TYPE OF CASINGISTEELIPVC {'V(pl DIA.OF WELL CASING _ p ❑ PUBUCIMUNICIPAL !!!❑DRIVEN DEPTH OF GROUT SEAL-6-5. SPECIFICATION A ❑ IRRIOATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E MONITORING GROUT SEAL PUMpEb: ❑Yaa [IN o CONCRETE PEDESTAL BY DRILLER:❑Yr ❑Ne S. ! /APPROX.DEPTH -- - LOCKING CHESTER BOXISTOVE PIPE ,g PROPOSED CONSTRUCTION LLINO METHOO: MUD ROTARY AIR ROTARY AUGER GABLE OTHER I HEOkSY 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:'I 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 SUBZONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: •I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' C T CALL 24 HOURS IN ADVANCE MIR ALL REQURED INSPECT}ONS T 12OY1�S5_44I/122. COMPLETE DRAWING AT LOWER AREA PROW' ED 7 Signed X Titl Gam.-. Oats qA PLOT PLAN(Draw to Seale)Seale •to ' 1. NAM"10NEDO ADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED ..2.-OUT ,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMO AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.—, DEPARTMENT USE ONLY Application Accepted By Dete Arae r Grout Inspection By Dote Pump Inspection By D.I. Destruction Inspection By i •e Comments: 1A IV V r ` ACCOUNTING ONLY: AID# FAC* PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE y lith 64Q