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9 APPLICATION FOR WELLIPUMP PERMIT'_" !` (teoSAN JOAQUIN COUNTY PUBLIC HEALTH SER" i ENVIRONMENTAL HEALTH DIVISION 6 P,O: BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201988 _.. .. 12091490-3420 ! NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ! {Complete In TTIPWNtd APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 18 MADE IN COMPLIANCE WfTHSAN JOAQUIN COUNTY DEVELO11PpMENT�ITITLE,CHAPTER 9-1115.3 R.'0__ nAND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH 6ERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN#1$D 1 Do V IA< a A Q ___ __CITY ST PARCEL StZFJAPNO r Q OWNER'S NAME A 1 I •r 1 n S _. _--.__ .. ADDRESS OV IGS" n O �A PHONE I y 77 b o b lo:: �R. L�,' lA1e�K � pC1 CONTRACTOR - A. C ADDRESS W G £ LICA;►^ PRIONE R 7 d g-_.Q BUB CONTRACTOR E AD S TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MON TTORIW WELL# 11 ❑ OTHER ❑ INSTALLATION -❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J h 1 13 Now 13 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL t7 (TYPE OF PUMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I X!4 SOILPING �.�LD-Am'.+— e i ❑DESTRUCTION: � Ia +0 S s•l� P S } �h INTENDED USE TYPE OF WELL Ih CONSTRUCTION SPECIFICATIONS T A ❑ INDUSTRIAL ❑OPEN BOTTOM 6 DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASING D ❑ DOMESTICIMVATE ❑GRAVEL PACKISIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASING D ' ❑ PUBLFCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION ' R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY �� GLUT BRAND NAME E '! ❑ MONITORING : GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER:❑Yee ❑No .5 APPROX.DEPTH .f LOCKING CHESTER BOX/S'TOVE'PIPE S 1 PROPOSED CONSTRUCTIONMRILLING METHOM:�MUD RtOTARY AIR ROTARY AUGER CABLE OTHER I HERESY CERTIFY THAT I HAVE PREPARED THIS!!APPLICATION AND THAT THE WORK WILL RE DONE IN ACCORDANCE WITH SAN 110AQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-t CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES 7 THE FOLLOWING: -I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,1 SHALL EMPLOY,PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA:' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION$AT 1211$1 4$R]422. COMPLETE DRAWING AT LOWER AREA PROVIDED. •'. 6I I"' Signed X '! Titie s i-t4 F LE G 4 e!1l O a l-S+. _._ __3 Det. S+ 4 n�t" PLOT PLAN(Draw to Serle]Seateto 7.,, ` :h 1. NAMES OF STREETS OR ROADS NEAREST TOORBOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE Of THE PROPERtV,GIVING DIMENSIONS AND NORTH DIRECTION. EXPAA1910N OF SEWAGE DISPOSAL SYSTEMS. t 7. 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. , ..... .. ..-:,..,.. :. _ - V< ID1 da - ...:,. .II..:.- .. ., -. .,. .. .. .... 1 :..... .. -.... .....,.. ., I - _ 1 I� DEPARTMENT USE ONLY , 1 L//j .F \A,Plicatlan Accepted By Date [ Arae r0 1 I ! q out InspectionF1 Onto'�( Pump Inapection By Date Denructlen IrnPectI B Date Cem te: fi -3 c ,t � 1.�2. . ACCOUNTTIING ONLY: ®AtD#� FAC# � h PE CODES PEE INFO AMOUNT REMITTED CHECK/IC ASH RECEIVED 9Y D TE PB1M1T1tFR1ACE REQUEST NUMBER INVOICE