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APPLICATION FOR WELL PUMP PERMIT, 'SAN JOAQUIN COUNTY PURL C HEALTH SERV,,_,:S ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 904 EAST WEBER AVE 4UE. STOCKTON, CA%Mj0 388 (209) 468.3 20 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE 1N COMPLIANCE WITH SAN JOAOUIN COUNTY DEVELOPMENT TITLE,/CHAPTER 8-11111 5,.3 O THE STANDARDS OF SAN JOAQUINCOUNTY PUBLIC HE LTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOBADDRESSIORAPNI airs- /_" Cr,ac- h'Lg U+ _CM PARCEL BIZFJAF"V OWNER'S NAME , OA.mGyh dJ'91r1 ADDRESS q -�--- PHONE 0 CONTRACTOR D f h ADDRESSZ Aq ej /Ilik- UC# PHONE R SUB CONTRACTOR_ IYI W tCI 51LZ PHONE s .. I TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING LL/ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONN CT REPAIR ❑ VAPOR EXTRACTION WELL I J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p i (TYPE OF PUMP) L7 y� ;7 ,/�' ' ElOUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL$ SOIL BORING /� I-_�,[ ` 06LC— o -I��B ' 13 DESTRUCTION: `S I ` ZS INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISIZ£ TYPE OF CASINGISTEELIPVC DIA.OF WELL CASING D ❑ PUBLiCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME � �t E ❑ MONITORING GROUT SEAL PIMPED: ❑Y ❑No CONCRETE PEDESTAL BY DRILLER:❑Yr ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE g I PROPOSED CONSTRUCTIONMRILLING 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 CCOAnANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERI FIEB THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH i T ISSUED,I SHALL NOT EMPLOY PERSON SUBJECT TO WORKMAN'$COMPENSATION LAY S OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES HE FOLLOWIN 'I CERTIFY THAT IN THPERFO ANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPEN$A-DON LAWS OF ALIFORNIA.' F_APPUCANT US LL 24 1 VANCE FOR ALL REQUIRED INSPECTION$J T 1200)40$,3423, COMPLETE DRAWING AT LOWER AREA PROVIDED. q Signed Title Date__.�ll•� ! PLOT PLAN{Oren to Scale)Scale o 1. NAMES OF STREETS OR ROADS TO OR BOUNDING THE PROPERTY. 4, LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,Of DIMENSIONS AND NORTH DIRECTION. - EXPANSION OF SEWAGE DISPOSAL SYSTEMS. _ _ - ... ..-,.... .,... A :rf ....... ............................:......:.... r DEPARTMENT USE NLY Application Accepted By Data Area Grout Inspection By ate I Pump Inspection By Date Deetroctlen Inspection By e i Date Comments ACCOUNTING ONLY: AIDR FACT PE CODES FEE INFO AMOUNT REMITTED CHECKIICASH ✓✓✓ JJJ 10 RECEIVED BY DATE PBVu1TISERVICE REQUEST NUMBER �0 INVOICE 4=- II G 0 �