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APPLICATION FOR WELLIPUMP PERMIT �AYMENT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES R�� ® ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST„ STOCKTON, CA 95201-388 SAN JG.;,Litl`I Gi),,lNTV (209) 468-3420 �,�VI�' 5 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED PUBLIC HirAt-Y� � ` FnN�IRONMEM i AL HEALTi4 DIVISION (Complete in Triplicate) APPUCA O 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 COMPUANCE WITH SAN JOAQUIN COUNTY DEVELORMENNT YLE CHAPTER 9-1115.3 AND ,THE �STAND/ARDS Of SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN* J//�, ,� S» �� ,[.�/Yllf� CITY �fS/7Ol�� 21 PARCEL SIZE/APN*1p77-.77C7'+C-vA%-JI2 OWNER'S NAME—/-347 �I h' >/ .-L•7V-7I ADDRESS 06;: 7 7A! 14,n�eJ�Lj" ��s,2r!J� PHONE�J y//•3��7 CONTRACTOR 6:Le4ll�9 le-al r�/�1r C�...T 1/ �' -r-^7G ADDRESS /y� �Q/,Jt�Y h�:1 UCX �r .� PHONE T SUB CONTRACTOR ADDRESS LIC* PHONE TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL* ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL* ❑New 13 Repair H.P. DEPTH PUMP SET FT. (TYPE OF PUMP) �F,IR/ST WATER LEVEL G O OUT-0F-SERVICE WELL 13GEOPHYSICAL WELL* LAS SAIL BORING /` 3 ❑DESTRUCTION: 13 INTENDED USE TYPE OF WELLCONSTRUCTION SPEr1F1CATIONS / �,/ A 13 INDUSTRIAL OPEN BOTTOM DIA.OF WELL EXCAVATION J-� y DIA.OF CONDUCTOR CASING .1!1�'T p ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING-. L1(� p ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER r %y GROUT SEAL INSTALLED By 11 MONITORING t•-e7�� GROUT BRAND NAME E APPROX.DEPTH GROUT SEAL PUMPED: ❑Yee No CONCRETE PEDESTAL BY DRILLER:❑Y. ❑No S _ �(� / � � 1y LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONETRUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT 1 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 SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT R SUB-CONTRACTING COMPENSATION LAWS Of CALIFORNIA.' TH�APPUCANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120014693423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X Title__ t'—y�/' �S�— Data . PLOT PLAN(Draw to Sulel ScaN •to 22 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. 3. 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. .... DEPARTMENT USE ONLY Application Accepted By Date � Ansa Grout Inspection By Dat Pump Inspection By Date , Destruction Ins tion By p Date Comments: ACCOUNTING ONLY: AID* FAC* PE CODES FEE INFO AMOUNT REMITTED CH ASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 33 101 ZvRZ LE- b �T/E6 CIO 2-