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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SER ,_ n ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 (209) 4683420 NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED fro JZ3-[EBZ,Z7,� ASD (Complete 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. JOB ADDRESSOR AP/NT ' G/ .r`-�!� 'V �� VUV� CITY ^,.1/�-+�/'J PARCEL SIZE/APN# OWNER'S NAME �^�+�C�r �� T �t`' '�--y� ADDRESS �A*�I K/ /n.�..�//1'I `/�//� r�'1 /1�I /PHONE• CONTRACTOR ��/1 K-UL r I �JL Y I �V U I ADDRESS O/Jl[J_5 (.y iSc>J4m CMI S� 1(/ PHONE# SUBCONTRACTOR ADDRESS UC# PHONE TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ 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 ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# 801E BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTICR'RIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Vs [IN. CONCRETE PEDESTAL BV DRILLER:❑Ys ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILUNG 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 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: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFO HE APPLICANT MUST CALL INI11116 IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12081,1/4�L88C3(\4V.CCO�MPLE�I'T/E��DRAWING AT LOWER AREA PROVIDED. SIprKM X Title 1 / 1 1 1 1 �J..9-J I�1 t"1 I ! Date PLOT MAN (Draw to S Ie)Scale 'to 1. NAMES OF STREETS OR ROADS LREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMEN61ONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTUNF.S 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. ...t i. ._.. ...... ..... ..... ipost-I1TM brand fax transmittal memo 7671 #D7 pages, F ... From /-Ln . . .. . . Co. ` f . Phone# ..... ... .. Dept. Fax# Fax# ._ .. .... DEPARTMENT USE ONLY Appll tion Axeptee B a 1 Date Nr \J Groh Impaction By Data Pump Impectlon By Data Dmtr.0.I.Wtion By ' ^ to Comm.. D N\ byv a ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#MASH RECEIVED BY DATE PERMIT/SERVICE REQUEFr NUMBER INVOICE (� -0 job UC1 Z1