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APPLICATION FOR WELL►PUMP PERMIT 4j S7D7`gS SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES v_ ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (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 T ,CHAPTER '9--111 5.3 AND THE STAND{y/�qp�S'OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN* I 164 •^— // //^^�XM CITY S AP6j--/y �/J PARCEL SIZE/APNX OWNER'S NAME FY' • Z 13 Ct k� 6tb DDRESS �� ?J 46D1-•t PHONE CONTRACTOR �f 01— ADDRESS �+ �' LIC* Z 111?2*idNE I 1 SUB CONTRACTOR `a` LN.0• ADDRESS,ZYZ /L�y/u//y/ LICK ZZ&O PHONE N 416 TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL* (TYPE OF PUMP) J 13 Now 13Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ` l ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL N 13SOIL BORING -Og )4DESTRUCTION: I J w.G ` moi/ 41"PUL Pr(�SSCA rt 9►'Os INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION 116 ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME ❑ MONITORING GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLFR:❑Yea [IN. S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING 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 PE S IS D,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE OWING: CERTIFY THAT IN THE PERFC RM E OF E WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFO IA." THE CANT MUST�Amb� N AD FOR ALL REGUIMED INSPECTIONS AT f2091468-3423. COMPLETE DRAWING AT LOWER AREA PR(O//tJyDED. A Signed X Title Date I PLOT PLAN(Draw to Scale)Scale "to 1. NAMES OF STREETS OR ROADS NEA 0 OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVIN ENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOC ION 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. -` DEPARTMENT USE ONLY Application Accepted By / � ✓ Arm Date Grout Inspection By Date Pump Inspection By Date Destruction Inspection By -~ � ( Date Comments: ACCOUNTING ONLY: AID# FAC* PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DAT PERMIT/SERVICE REQUEST NUMBER INVOICE