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APPLICATION FOR WELLIPUMP PERM41_/_ p <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON. CA%Mj X88 <br /> (209) 468.3420 <br /> NON-REFUNDABLE PERMIT EXPIRES-I YEAR FROM DATE ISSUED <br /> Womplete I <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDr OIRINSTALL THE,WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH 8AN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRE88/OR APN# 7 qi �/ � �- ( ,r�, - CITY_ ���C L/t T <br /> I / PARCEL SIZE/APN#ZG'5. I rr <br /> OWNER'S NAME I t <br /> ADDRESS �'';''�'? v• k_j � PHONEM <br /> CONTRACTOR- ) /iADDRESS ��G. ` Ci/l•'1Z <br /> i <br /> PHONE <br /> SUB CONTRACTOR C,% '141 1 —IT <br /> y S UC# PHONE# <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL' <br /> El OTHER <br /> ❑ INSTALLATION 11 WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# <br /> J <br /> New❑Repair H.P. FT. FIRST WATER LEVEL <br /> RYPE OF PUMP) DEPTH PUMP SET U <br /> ❑❑ OVT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑� &OIL BORING <br /> B DESTRUCTION: <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 11 <br /> .Z ->t DIA.OF CONDUCTOR CASING A <br /> 11 O <br /> DOMESTIC/PfpVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO <br /> D <br /> PUBLICIMUNICIPAL IJDRIVEN <br /> 11 IRRIGATION/AO El OTHER DEPTH OF GROUT SEAL - -� .,t,? SPECIFICATION R <br /> -` � <br /> GROUT SEAL INSTALLED BY -r" . �. �, LA'i r GROUT BRAND NAME O Ci:'4' ( E <br /> ❑ MONITORING GROUT SEAL PUMPED: ❑Yes .®No CONCRETE PEDESTAL BY DRILLER:❑Yee ❑No S <br /> APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S <br /> PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER ✓r CABLE OTHER <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN 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:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR$UB-CONTRACTINO SIGNATURE CERTIFIES <br /> THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1$HALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFORNIA.- THE ACANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1200)400-5422. COMPLETE DRAWING AT LOWER AREA PROVIDED. <br /> f{ A I I <br /> signed X �..I✓'( 7!L,l.,.� G..,,l- 1� Title <br /> ..x ` Date- <br /> PLOT PLAN(Drew to Basis)Sulo "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 WALK$. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> DEPARTMENT USE ONLY <br /> Application Accepted BY Dalee�(a Area <br /> Grout Inspection By ` Date Pump Inspection By Date <br /> Destruction Inspectlon By Date <br /> Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMITISEAVICE REQUEST NUMBER INVOICE <br /> R' <br /> i <br /> 1a! <br /> Post-it®Fax Note 7671 Date /1► pages- <br /> _ To b I / From <br /> V <br /> Co./Dept. Co. ri <br /> Phone# Phone# <br /> Fax# CWA. <br /> Fax# <br />