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I AFPLICATIOA! FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVdtS ' ENVIRONMENTAL HEALTH DIVISION PAYIW P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9520I-38%ECjElET ® (209) 468.3420 MA R 0 4 1596 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN ic" (; {CompMts In TrtpIkatal 1�1tPUBLIC H 0UNTY U7fT +��+ APPLICATION 1$HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.TE18` OrpJYrNTAI.`�LE! I`�OrOIew WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1 115.3 AND JHE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICER,ENVIRONMf JOB ADDRESSOR APN# CITY 71/yV_J 1 PARCEL/SIZEJAPNI V OWNER'S NAME e (� ` �,r11[ _ ADbRESB Sl Xp r~/(J S[ PHONE/ CONTRACTOR .C3 r1�nt 1)"A' r u ,ADDRESS CI�—PHONE BUB CONTRACTOR ADDRESS LICE PHONE# TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER - f ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑.CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ,/ 13 Nam,13 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p (TYPE OF PLIMPI ❑ OUT-OF-SERVICE WELL ❑'GEOPHYSICAL WELL# SOIL BORING r R ❑DESTRUCTION: ' INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A } ❑ INOUSTRIAL ❑OPEN BOTTOM DIA,OF WELL EXCAVATION /�/N ULA.OF CONDUCTOR CASINO p I} ❑ bOMESTIC1PFgVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/6TEEUPVC DIA.OF WELL CASING D II ' ❑ PuSUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION � R ❑ '1 , y IRRIGATKINIAG ❑OTHER { GROUT SEAL INSTALLED BY GROUT GRAND NAME _l 6" F I�/ MONITORING GROUT SEAL PUMPED: ❑Yes ❑No CONCRETE PEDESTAL 9Y DRILLER:❑Yr [IN. S. J APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S II PROPOSED CONSTRUCTIONIMIJJNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLEL OTHER I HMSY 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 SIONATURE CERTIFIES THE FOLLOWING;'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH 4 l 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: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF i CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001 4"3423COMPLETE DRAWING PROVIDED. . WING AT LOWER AREA PRI A : G Il ~� Slpnad X TLt1a ,e t7/6 / / Date �/ h PLOT PLAN{Drew to Scelel"a "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. 9. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING ANb PROPOSED 6. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT.. STRUCTURES INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALK$. ON THE PROPERTY OR NO PROPERTY Y 411.5ale— ` k `... ham Ab r : ........ : .. _ .... ..:. I ... I DEPARTMENT USE ONLY Application Accepted By_ ._Dete `t-� Area ✓�O `� Grout IrnPectlon By Date Primp Inspection By Date Dwtructlon Inspection By Date r' � Comments: t� ACCOUNTING ONLY: AID# FACE PE CODES FEE INFO AMOUNT RWITTED CHECK#ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE ' 360-)