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APPLICATION FOR WELLIPUMP PERMIT r+/SAN JOAQUIN COUNTY PUBLIC HEALTH SERV ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED lCompiete 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 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JQB ADDRESSOR APN# 93 w. 7 krWA CrrYt /J`/�� t J PARCEL SIZEIAPN# 2 OWNER'S NAME T ADDRESS fes_0. f3 Ix ) 6 C�7'�j PHONE'4'6 5rk'47 CONTRACTOR K +✓ � j �J J r, 7��j ADDRESS_3,o�l�r lL,D g 'C#-5&4+6P PHONE#?1S— '�� SUB CONTRACTORC�- 1 Il1L/f�Q I .ILIIT . 7 r�G LJ ADDRESS V?t, WQfU7 b7 e� LIC#' PHONE dJ TYPE OF WELIJPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Repair H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL O fIYPE OF PUMP) 1 / ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL it SOIL BORING 1 % 8 ❑DESTRUCTION: INTENDED USE TYPE OF WELLCONSTRUCTION SPECIFICATIONS // A 13INDUSTRIAL 13OPEN BOTTOM DIA.OF WELL EXCAVATION a►& DIA.OF CONDUCTOR CASING 'VIA O � PRI DOMESTICIVATE 11v GRAVEL PACKISiZE TYPE OF CASINGISTEELIPVC l� 1 DIA.OF WELL CASING IV4A D © PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION N/ R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME PI 1.1 11.171 i MOW E ❑ MONITORING GROUT SEAL PUMPED, L3 Yee ❑NoJJ}} CONCRETE PEDESTAL BY DRILLER:❑ w ❑YNo S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE AVA S PROPOSED CONSTRUCTION1MULING METHOD: MUD ROTARY AIR ROTARY AUGER X 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,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORIOAAN-6 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'6 COMPENSATION LAWS OF CALIFORNIA' T MUST C HOURS IN ADVANCE FOR ALL REQUIRED INSPEE�C�TK1NS AT(22009)441683423. COMPLETE DRAWING AT LOWER AREA PROVID/ _ Signed X Title a�/�i/ _-�I Data !sr PLOT PLAN (Draw to Scale)Scale "to I. 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,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. 60- DEPARTMENT USE ONLY Application Accepted By � Date 'V Area Grout Inspection By Data Pump Inspection By Date Destruction Inspection By Date Comments: q-� ACCOUNTING ONLY: AID# FAC# s`� PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE