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APPLICATION FOR WELL)PUMP PERMIT , SAN JOAQUIN CtUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O, BOX 388,304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplet9 in T►ipfieete) 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 WITII SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 110 --AND THE STANDARDS STANDARDS OF SAN JOAQUIN COUNTY PUBLIC IIEAyrLTT14 SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN# /2J S. �ev1 '"t ✓'_. Cirv, V"` PARCEL SIZE/APH LillOWNER'S NAME G Y,CN L/ ADDRESS �. S�- / �"`�`y--T�—J'. _PHO CONTRACTOR �(J•Ciyl/�,� L ` ADDRESS UCI PUB CONTRACTOR ADDRESS a3/G 7 L4) � Lj WC9N-1 UCN S 1ZPHONE D TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL D ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O IT VPE OF PUMP) ❑ OUT --Or-SE VICEtWELL,,D r,❑ OEOPHY ICAL WE SOIL❑ SOIL BORING B DESTRUCTION: C 'e T&A 1 Z C� I'✓` O l V ��[ /k INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS All A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION �LI DIA.OF CONDUCTOR CASING7 - p 11DOMFSTIC/PRIVATE ❑GRAVEn L PACK/SIZE TYPE OF CASINO/STEEUPVC F-'uL- DIA.OF WELL CASINO ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING I GROUT SEAL PUMPED: ❑Yea [IN. CONCRETE PEDESTAL BY DRILLER:I&aa []No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE 5 PROPOSED CONSTRUCTIONMAILUNQ METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT t 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 Wolk FOR WHICH THIS PE D,'SHALL NOT EMPLOY PERSON.SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'.HIRING OR 9U8-CONTRACTINO SIGNATURE CERTIFIES THE I LOWING: - CERTIFY THAT IN THE PERFORMANCE CITHE WORK FOR WHICH THIS PERMIT 19 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CA RNIA.' THE A CANT MUST ALL NO IN A CE FOR ALL REQUIRED INSPECTIONS AT(209)499-8428. COMPLETE DRAWING AT LOWER AREA PROVIDED. 910ned Xw 7�9 9 Title C,// Date / / PLOT PIAN(Draw to Sahel Seat@ 'to 1. NAMES OF STREETS OR ROADS NEAREST OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROfPOM 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SY97EM8. 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, . _ w DEPARTMENT USE ONLY 7 APPlieatlon Accepted By Date_ :: ( �7 Area Grout Impeetlon BY__ Date Pump Inepeotlon By Date Oeatramtlon Irnpeellon B s Data Cemmdrty -- ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED By DAT may_ PERMIT/SERVICE REQUEST NUMBER INVOICE Pub.Health Serv.-Enviro.173(3/96)