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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERI ; ENVIRONMENTAL HEALTH DIVISION P•O• BOX 388, 904 EAST WEBER AVENUE, STOCKTON, CA 95201388 I209I 466.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED - (CGmplen In T#IpliCEI#) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED. THIS APPLICATION tG MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT //TITLEE,,(CHAPTER 9- 1115,3-. AANND THE STANDARDS 1OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES, ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR IAPPPN�N# /�q Q& ry '1 - �I �y/�V�le Y�� • U r ` e— CITY _11�+Y IAr��I(yYi'fT/�,Y,N Z PARCEL SIZE/APN# �,/�1p j� OWNER'S NAME 1 1 /LO (I � L{, JS CZ L ADDRESS p1 ' �O`V, lJ /z_ W 5JL5 PHONEN it � � /J�� CONTRACTOR �b^` `O[X�(1 / vel 116, ADDRESS i• a37c3✓b RID V WC# ssr �0AP10NE # ��•Y SUB CONTRACTORbbbb^^^V^�`" ADDRESS LIC# PHONE# TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL # ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # J 11New 11Repelr H.P. DEPTH PUMP SET_FT. r FIRST WATER LEVEL O ITVPE OF PUMP) p.Is II 11 OUT-OF-SERVICE WELL . v. /l❑ GEOPHYSICAL WELL 0 1� /; ! / � ! ❑ SOIL BORING ^ )� p��,ry� B DESTRUCTION: �'I I� �.7af M &U Ig 0 &% 10" d IE�• r 1C'c. ) d L/ acQ'i / I LI.� r% . /may&cemefl� t r ` ? INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑ OPEN BOTTOM DIA, OF WELL EXCAVATION DIA. OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC CIA, OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑ DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG 11 OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑ Ys [] No CONCRETE PEDESTAL SY DRILLER: ❑ Ys ❑ NO S APPROX. DEPTH LOCKING CHESTER BOX/STOVE PPE S } PROPOSED CONSTRUCTION/DRILLING 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, ANO 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 WOR( FOR MICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.• CONTRACTOR'S HIRING OR SUBCOWRACTING SIGNATURE CERTIFIES THE FOLLOWING: • 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, 1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.•/THEE//,E/�PUCANT MUST CA HO SIN ADVANCE FOR ALLREQUIRED INS TIONS AT 12MI 4Ba3423. COMPLETE DRAWING AT LOWER AREA PROVIDED.. Slpned X ( �( ////�Ce ,7 Title T? <pd Ax, (1 7 Date d/7C5 tilt PLOT PLAN (Draw to Seals) Seale • 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. 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 / � ` ` Area Det Grout Impaction B Date Pump Inspection By Date Dstruetlon I psllon BY Dale Comment.: ACCOUNTING ONLY: AID# FAC# L FEEINFO AMOUNT REMITTED CHECK#/CASHH RECEIVED BY DATEr/� p PERMIT/SERVICECREEQUUOESSTT NUMBER INVOICE 7