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APPLICATION FOR WELLIPUMP PERMIT <br /> AN JOAQUIN COUNTY PUBLIC HEALTH SERVIk, O <br /> ENVIRONMENTAL HEALTH DIVISION <br /> P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTOIJ, CA 95201.388 <br /> (209) 468.3420 <br /> D00-REFUUDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Comploto in Triplicato) <br /> APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN <br /> JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 A THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC <br /> HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. <br /> JOB ADDRESS/OR APN# ZZ JCAgLd �J. CITY S/—'LiCi�Yl PARC/E�L+/S�IZE/APNX <br /> OWNER'S NAME D / Irl Cif"ADDRESS 1/ .II'V/N C PHONE 1 �5� <br /> CONTRACTOR�r/ii A /%"//1��1 0' ADDRESS/.S U W if—g A-4e;?; LICK SI PHONE A00 <br /> SUB CONTRACTOR ADDRESS LIC# PHONE# <br /> TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER <br /> ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J <br /> ❑New 13Repair M.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O <br /> (TYPE OF PUMP) `�y, <br /> 1:3 �S <br /> OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# P( <br /> SOIL BORING 0)1 B <br /> ❑DESTRUCTION: / ` <br /> INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS /j A <br /> ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION !) r vi DIA.OF CONDUCTOR CASING 0 <br /> ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D <br /> ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION // /J R <br /> ❑ IRRIGATION/AG ❑ b/`T OTHER GROUT SEAL INSTALLED BY �//�� h GROUT BRAND NAME 11.K '� E <br /> MONITORING GROUT SEAL PUMPED: 13Y. ❑No y�C ��lC�lq CONCRETE PEDESTAL BY DRILLER:13Y. ❑No S <br /> ffl <br /> APPROX.DEPTH 22LOCKING CHESTER BOX/STOVE PIPE <br /> ` S <br /> PROPOSED CONSTRUCTION/D NO METHOD: MUD ROTARY AIR ROTARY AUGER !„I CABLE OTHERLM (f JP <br /> 1 HEREBY 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 <br /> REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH <br /> 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 <br /> THE FOLLOWING: "I CERTIFY HAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF <br /> CALIFO ANT3, M96,v <br /> 24 NO IN AD NCE FOR ALL REGLZRED PECTIONS AT(208)4083423. COMPLETE DRAWING/ LOWER AREA PROM QED <br /> Signed X — / z/, / <br /> / � Title, ra� 0 Data <br /> PLOT PLAN(Draw Scale)Scale "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 WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. <br /> ... ..... .... ..... I <br /> DEPARTMENT USE ONLY (/p/ (�P, <br /> B C <br /> Application Accepted Date Area y <br /> Grout Inspection By Date Pump Impaction By Date <br /> Destruction Inspection By Date <br /> Comments: <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE <br />