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APPLICATION FOR WELLIPUMP PERMIT SAN JOAiIUIN COUNTY PUBLIC HEALIII SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9S201-388 (2091 408 aazo ETON REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED Wompla(y In Triplicate) APPLICATION 15 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED THIS APPLICATION IB MADE Ila COMPLIANCIP WITH SAN JOAQUIN COUNTY DEVELOPMENT+TITLE r �JCH�A�PTER79 1115 3 AND THEK1TANDARDS OF SAN JOAQUIN COUNTY HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION JOB ADDRESSlOR AA1110NM } q Y�t1�-- (e�,,j)o ';(I�►�/ CITY 1 J f ' PARCEL SIZEIAPNR OWNER a NAME �.`� ADDRESS E 11 f,I�1f I^f� r'� f f�f�<-I 1 PHONE#f' CONTRACTOR Q N, rQ'.li r f fy 5Y t 1{-3{ % T ADDRESS I 7r9 r 'i 1;j JA (/\ucx C. � 1✓�I � � � PI LONE M SUBCONTRACTOR i�� (� )�� M( r...Irw1C ADDRESS rxIo 1If1Pff P1,P I If trl� tICM 51t45 PHONE TYPE OF WELLMUMP 0 NEW WELL ❑ REPLACFMENT WELL ® MONITORING WELL# E ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS CONNECT REPAIR ❑ VAPOR FXTRACTION WELL# J (TYPE OF PUMP) 11 New❑Repair "P- DEPTH PUMP SFT FT FIRST WATER LEVEL O ❑ OUT OF SERVICE WELL ❑ GEOPHYSICAL WELL R ❑ 801L BORING R ❑DESTRUCTION INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM 1 L DIA OF WELL EXCAVATION �� + DIA OF CONDUCTOR CASING ❑ DOME STICIPRIVATE El GRAVEL PACK/SIZE ��^ Ih TYPE OF CASINGlSTEEUPVC I'Ya'?_ DIA OF WELL CASING_ ! p ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL N twSPECIFICATION �f! ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY (1 r r 1 {''"' GROUT BRAND NAME F IJ MONITORING _- la if GROUT REAL PUMPED Ely. ❑ ❑No CONCRETE PEDESTAL BY DRILLER Yea ❑No S APPROX DEPTH_ LOCKING CHESTER BOXISTOVE PIPE 5 PROPOSED CONSTRUCTIONIDRI>_LIHG METHOD MUD ROTARY AIR ROTARY AVOER—_Y�._CABLE OTHER IY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WALL BE DONE IN ACCORDANCE IMTN SAN JOAQUIN COUNTY ORDINANCES STATE LAWS AND RULES AND I TIONS OF THE SAN JOAQUIN COUNTY HOME OWNER OR LICENSED AGENTS SIGNATURE CERTIFIES THE FOLLOWING I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICIt T tRMIT IS 1SSUE0 I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN S COMPENSATION LAWS OF CALIFORNIA CONTRACTOR a HIRING OR SUB-CONTRACTING SIGNATURE CEFrt]FIE( THE FOLLOWING 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN S COMPENSATION LAWS Or CALIFORNIA THE APPI3C/A�JiT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12001460-3423 COMPLETE DRAWING AT LOWER AREA PROVIDFO ,I ! ? j ' D.tasigned x Till e ' c + + T� PLOT PLAN 10t&W to Scale)Scale 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 OUTLINFS AND LOCATION OF ALL EXISTING AND PROPOSED 6 LOCATION OF WEt-LS WITHIN RADIUS OF ONE HUNDRED FIFTY FT STRUCTURES INCLUDING COVERED AREAS SUCH AS PATIOS DRIVEWAYS AND WALKS ON THE PROPERTY OR ADJOINING PROPERTY S �l f DEPARTMENT USE ONLY Application Accepted BY `� --�' .1f ( 4'_-M ° Date r f` ! }/•f Grout Inspection By (+ Date Pump Inspection By Date Destruction Inspection By Date Comments ACCOUNTING ONLY AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#!CASH RECDVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE