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Ir I APPLICATION FOR WELLIPUMP PERMIT �iimiiWSAN JOAQUIN COUNTY PUBLIC HEALTH SERS ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKMN, CA 95201 w (209) 460-3420 j NOM-REFUNDABLE PERMIT EI(PIRES 1 YEAR FROM DATE ISSUED 1Compl9t9 In Trlplicat$I APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT 70 CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION 16 MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOS ADDRESSIOR APN#�,,Ljl l 1 '1 vel 1j - CITY PARCE!SREIAPNiGSC)OWNER'S NAME► 1fiS1� 7ADDRE68 'rCJIG YJ ZC�� PHONE 0CONTRACTORV 4I�� I 1,tn tx/, .,. U 1 LIC# �f -O d / ADORE68 !/[�'-6']S_PHONE 0.374f-281,1: Y BUS CONTRACTOR (�!/9 G ADDRESS it Ii LIC# PHONE# TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL Va MONITORING WELL IF ❑ OTHER # ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR w� ❑ VAPOR EXTRACTION WELL+ ,/ r ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL` f (TYPE OF PUMP) O ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING S ❑DESTRUCTION: ` INTENDED USE TYPE OF WELL CDNSTRUCTION SPECIFICATIONS !+4 © INDUSTRIAL ❑OPEN BOTTOM ' II A VIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING f O ` ❑ DOMESTtC/PMVATE ❑GRAVEL PACK/SIZE ( TYPE Of CASINGISTEEL/PVC L-- .1 DIA.OF WELL CASING_ /y D ❑ PUBIJC/MUNICIPAL ❑DRIVEN DEPTH OF OROUT SEAL_ Syore#r SPECIFICATION Gh L� x ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY_C '7y a,[r'o✓ GROUT BRAVO NAME '� E ig' MONITORING GROUT SEAL PUMPED: Yr [IN. CONCPETE PEDESTAL BY DFULLER:❑Yr [gNo S APPROX.DEPTH �r LOCKING CHESTER BOXISTOVE RPE V FS S PROPOSED CONSTRUCTIONIAR(LUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE9EBY CERTIFY THAT 1 HAVE PREPARED THIS APPMATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN`$COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTINQ SIGNATURE CERTIFIES TRE FOLLOWING: 'I CERTIFY HAT IN THE PERFORMANCE OF THE WOFK FOR WHICH THIS PERMIT IS ISSUED,i SHALL EMPLOY PERSONS SUBJECT TO WORKMAN•$COMPETI$AvON LAWS OF CALIFORNIA.' T C N MUST C 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1209)44"4421. COMPLETE DRAWING AT LOWER AREA PROVIDED. 8fprrad X Tltle_!� Date 5 ' � ' s PLOT PLAN(Draw to etsalsl Sulo As "to fUir1 1, NAMES O ST ETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY. 1. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE HE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. 'I 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. F - .... .. - -- .. .. S .. ... .. -.. ..... ..... - '.. ��f - f..... - ..,.. ., ., . ...... .,....... .... ....... .......... .... ..,.. ...,..,..,.. .,..,.., ., -. -. - - - - ., .. I�05Nt;B'�SD19 . o � .. :.. tExlaysuorss k _ ., .. ., . Storage.Shed :. . OFFICE$... 6 C .. I�rMOVEID).. ... .. ... .!. A. ;... �Cp+L.E • 58-8" .. :. .:.... . ; ir `�— jy�}Mw 1'^^ I DEPARTMENT USE ONLY I� I Application Accepted By I Data Area IIGrout Inspection By Dot� Pump Inspection By bate Deatructlon Inspection By ! Date I Comments: - ACCOUNTING ONLY: AID# FAC#{i PE C/O�]DES FEE INFO AMOUNT REMITTED CH !CASH RECEIVED BY DATE �f PERMIT/SERVICE REQUEST NUMBER INVOICE V