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`%NWI APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 �I (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (%j J (Complete in Triplicate) APPLICATION IS HERE BY MADE 70 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!F SAN JOAQUIN COUNTY PUB C HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDR S/ APNA_ / ✓_jz/0 S( � J (/ .CI-TY `� � /' PARCEL SIZE/APNN / OWNER'S NAME_ e' 0 �(��,(C"\ 6werr--cro ADDRESS 5tj�' (JCT PHONEN iN — 7/ CONTRACTOR f I ADDRESS LICII`!�M PHONE X 30o SUB CONTRACTOR D L�# vy PHONE# TYPE OF WELLIPUMP: NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER 9INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR prlVAPOR EXTRACTION WELL#fur/3 r (TYPE OF PUMP) ❑New 13Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS /� A 13 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 10 In-rhl DIA.OF CONDUCTOR CASING/ ! D ❑DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC L DIA.OF WELL CASING //�f C�'/ D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL - r SPECIFICATION rp ❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME 6 lfhe✓ E MONITORING �� GROUT SEAL PUMPED: F1Yea ❑No CONCRETE PEDESTAL BY DRILLFR:❑Yea C1NoS 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 PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 CERTIFY THATINTHE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." THF„(1 NT MUST �L CALL RS IN ADVANCE FOR ALL REQURED INSPECTIONS AT/1209)-4}8883423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X Title PLOT PLAN(Draw 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 6. 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 j/' - Application Accepted By Dete ✓I I 1/T�{//y� /,�Area Grout Impaction By GI L Date t/C1 Pump Inspection 6y Date Destruction Impaction By Date Comments: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHEC'fK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE