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/ APPLICATION FOR WELLIPUMP PERMIT JOAOUIN COUNTY PUBLIC HEALTH SERVIC AD ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388. 904 EAST WEBER AVENUE, STOCKTON. CTR MOI- 88 1209) 468-3420 NON REFUNDABLE PERMCT EXPIRES 1 YEAR FROM DATE ISSUED APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE CHAPTER 8 1 115 3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION JOS ADORESBIOR APN/ CRY PARCEL SIMAPNO OWNER'S NAME ADDRESS PHONE# CONTRACTOR ADDRESS LK:# PHONE/ BUS CONTRACTOR ADDRESS LIC# PHONE# TYPE OF WE MPS ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MoNRORINO WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROBS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J RYPE OF PUMP) 1:1New❑Rapdr H P DEPTH PUMP SET FT FIRST WATER LEVEL O ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ som Boma 8 ❑DESTRUCTION INTENDED=E TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA OF WELL EXCAVATION DIA OF CONDUCTOR CASINO D D DOMESRCJMVATE ❑GRAVEL PACKISCE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASING O ❑ PUBLICAIIUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R nIM❑ IRKINRRIGATIONfAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAMf y E 13 ORING GROUT SEAL PIMPED [3 Yes [3 Ne Ne CONCRETE PEDESTAL BY DRILLER ❑Y. Ne S APPROX DEPTH LOCKINO CHESTER BOXIGTOVE PIPE S PROPOSED CONSTRUCTIONIDMIJUNG MIITHOO MUD ROTARY AIR ROTARY AUGER CABLE OTHER HE 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 11 N8 OF THE SAN JOAQUIN COUNTY HOME OWNER OR UCENsM AGENT 9 SIGNATURE CERTIFIES THE FOLLOWING -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH TH R 18 ISSUED 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR B HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES IEE FOLLOWING 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN S COMPENSATION LAWS OF :AUFORNIA.* THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120@)4"3439 COMPETE DRAWING AT LOWER AREA PROVIDED IFpned X TRIS Date PLOT PLAN(Drew to Settle) Soda to I NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY 4 LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED li t OUTLINE OF THE PROPERTY OIVWO DIMENSIONS AND NORTH DIRECTION EXPANSION OF SEWAGE DISPOSAL SYSTEMS 1 DIMENSIONED OUTLINFS 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 rew I DEPARTMENT USE ONLY ,ppllpatlen Adopted By Date Arae ,rout Impaction By Dote Ptanp Iropeetlon BY Date wtruetlan Impaction BY Dote ommerit� AMMUO ONLY AID# FAC/ PE CODES FEE INFO AMOUNT REMITTED CHEC"teASH RECEIVED NY DATE PEIRMITISEPIVICE REQUEST NUMBER INVOICE