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APPLICATION FOR WELLIPUMP PERMIT — SAN JOADUIN COUNTY PUBLIC HEALTH SERVI� _S ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N" SAN JOAOUIN ST., STOCKTON, CA 96201 .388 (209) 468-3420 ;N NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HEREBY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORT 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. Q JOB ADDRESS/OR, IAPNI,pII_nn�(A� E W CiTVCI'-'L fid WA..� CITY �oli;l !/,T./ �y� PARCEL SIZE/APNY y OWNER'S NAME/ND�a�a/1lU�A.) I C&&�Gn &M Co , ADDRESS PPI �)C ,1I` 10 (-.,.. e/�p�r/� PHONE #45a [+S' J� / CONTRACTOR C✓vC/V / "OND L ADDRESS 1803 W • 11V V V201 V" � UC# PHONE *00FIFFIFFIF SUB CONTRACTOR l7 Es D(L1l.l ly� yuu 1� A �n f p/ 707 1 ADDRESS /CJ 51 94& V �— JCKJ Z ( p PHONE #7 zc v Z?� IF TYPE OF WELL/PUMP: .LJ NEW WELL ❑ REPLACEMENT WELL �.MONITORING WELL Nf ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # ❑ New ❑ Repair H.P. DEPTH PUMP SET_FT. FIRST WATER LEVEL O (TYPE OF PUMP) Y ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL k ❑ SOIL BORING g A ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONSo - 1 A ❑ INDUSTRIAL ❑yyOPEN BOTTOM DIA. OF WELL EXCAVATION O DIA. OF CONDUCTOR CASING 7i rJ /AllO E ❑ DOMESTIC/PRIVATE . GRAVEL PACK/SIZE TYPE OF CASING/STEELF DIA. OF WELL CASING Z N D ,,,,�I ❑ PUBLIC/MUNICIPAL DRIVEN pEPTH OF GROUT SEAL �' For SPECIFICATION g ❑l IRRIGATION/AG ❑ OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E I,1 MONITORING µI i GROUT SEAL PUMPED: 1I Yes ❑ No CONCRETE PEDESTAL BY DRILLER: ❑ Ys ❑ No S APPROX. DEPTH.45 1 [70FIFFIFFIFFIF LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER_ CABLE OTHER 1 HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW 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 SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:1 "FI�CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S CONIMNS(A�TIIO�N LAWS OF CALIFORNIACy — LIOA#l1%MU&T CA 1NFO 161N ADVANCE R ALL REQUIRED r�8{T ZOS 23 E DRAWING AT LOWER DARER PROVIDED. 4 �L Slenetl X A Title G++l n PLOT PLAN (Drew to Scale) 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, INCLUDING COVERED AREAS SUCH AS PATIOS, DRIVEWAYS, AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. IN I IF I IF I IF IF ' DEPARTMENT USE ONLY Vn1 I Application Accepted By cit`— "' �" IIV \ Date l Area V� �1 Groin Inspection By Date Pump Inspection By Date Destruction Inspection By Date I Comments ACCOUNTING ONLY: AID# FAC# Fill' • �J 1 �R PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE