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`vw/ APPLICATION FOR WELL►PUMP PERMITS r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES `�"ZCj <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> 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 <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR APN# / 3 a�7 0 Z t <br /> �1C�, CITY �i PARCELGS_IGZ�IE//APN# <br /> OWNER'S NAME RVJG man ADDRESS .G pp �'q/ (- -I' PHONE N <br /> CONTRACTOR Y�� ADDRESS r©PO' 717tp tj LICK 5We? PHONE M �^39y-Wo <br /> SUBCONTRACTOR ��/ ADDRESS ( 7 ILICN PHONE.Y <br /> TYPE OF WELL/PUMP: Lal NEW WELL ❑ REPLACEMENT WELL 1:1 MONITORING WELL# ❑ OTHER <br /> ❑\INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR VAPOR EXTRACTION WELL <br /> ❑New❑Repair H.P. DEPTH PUMP SET FT. /` <br /> (TYPE OF PUMP) FIRST WATER LEVEL O <br /> ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING g <br /> ❑DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION p DIA.OF CONDUCTOR CASING I7 D <br /> 13DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEEL/PVC V DIA.OF WELL CASING 47 I/►G!7 D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL D +,�'- SPECIFICATION 1 R <br /> ❑ IRRIGATION/AG ❑OTHER GROAT SEAL INSTALLED BY D(1IGROUT BRAND NAMEd/'7 <br /> 91 MONITORING t GROUT SEAL PUMPED:glee ❑No CONCRETE PEDESTAL BY DRILLFR:❑Yea ❑No S <br /> APPROX.DEPTH (/ t LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTIONlDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER <br /> 1 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 <br /> 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 <br /> THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES <br /> 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 <br /> CALIFORNIA." THE AAP CANT MUST MURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209)4683423. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> Sloped X �(�ii!�!-�.�s Tine Ofd�OSCS� Data —ZZ—fS <br /> PLOT PLAN(Draw to Scale)Scale "to <br /> 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED <br /> 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. <br /> 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. <br /> STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ..... .. ..., .. C .....y <br /> JJJJJ <br /> ... .. ... <br /> ...... . .. Sem --�, ' ..���' \.. 2 <br /> s . . i 6 Vow ' Sfic r '.......:.....:...: :. <br /> ... <br /> DEPARTMENT USE ONLY <br /> Application Accepted BY Data �`-� � [ Area <br /> Grout Inspection By Date l Pump Inspection By Data <br /> Destruction Inspection By Date <br /> Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE RE UEST N ER INVOICE <br />