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y , APPLICATION FOR WELLIPUMP PERMIT SAN JOAOUIN COUNTY PUBLIC HEALTH SERVIt- d ENVIRONMENTAL HEALTH DIVISION P.O. 60X 388, 304 EAST WEBER AVENUE, STOCKTON. CA K"- I 88 (209) 466-3420 000•REFUODARIF PEBrmIT EXPIRES 1 YEAR FROA7 DATE ISSUED (Complate In TrIpHote) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT 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 APNI23goI 15 ChrisAna� -f-ac y CITY_ PARCEL SIZE/APNI/,2 9 ac res OWNER'S NAME SUbUrban Prp(xj//�Q n ^off -, n� I— iRAf !S� ADDRESS P0.6 2 , A)h --250-17- 6"t Co.15,/l —Q—L� W�1ylfP�/IN�PHONE I'BS7=5300 e+eRADDRESS22$o&tkfj� CDl1CnrSCfIUC# p/{ONE siq/ ZLI$S '0118CONTRACTORGrLI Dr;illAy s}�eCj��({ �jlC ADDRESS ISOoWe " � UCI $21 6s" PHONEII - SS� TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J New 11 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL (TYPE OF PUMP) O ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING h1ul I.2 3 t.t)i Il &c pre-ssu. 11rol"tk e � L 1� DESTRUCTION: �^ �� M� I�I.I�n�LC INTENDED USE TYPE OF WELL CONSTRUCTION BPECIFICATION6 A 1 ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D t Q DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATKINIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E / ❑ MONITORING GROUT SEAL PUMPED: ❑Y. ❑No CONCRETE PEDESTAL BY DRILLER:❑Vw ❑No S APPROX.DEPTH go, S LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTIONORLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AN r REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 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 N THE PE ANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN-6 COMPENSATION LAWS OF CALIFORNIA.' TH APPUC 2 IN ADVANCE FOR ALL REQtXREDD,INSPECTIONS AT 1200)4663423. COMPLETE DRAWING AT LOWER AREA PRO/DED. /y Signed X This 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 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. .... - i tCE i i ...:.. .. .....: .. .... ..:.......... ... I DEPARTMENT USE ONLY Application Accepted By Date Y_ Area Lf—')— Grout f—')—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 DATE PERMIT/SERVICE REQUEST NIAVImER INVOICE