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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 96201•388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES ! YEAR FROM DATE ISSUED (Complete in Triplicate) 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 [^. JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1115.3 AND THE STANDARDS OF BAN J OU COUNTY PUBLIC HEALTH S RVICES,ENVIRONMENTAL.HEALTH DIVISION. JOB ADDRESSOR APN# t IfY =' PARCEL SIZF1APN# OWNER'$NAME !. ADDRES6 CONTRACTOR PHONE AODRES LIC'a oo PHONE# SUB CONTRACTOR ADDRESS UC# PHONE,T it TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL• ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ffYPE OF PUMP) Naw❑Repalr H.P.• _—? DEPTH PUMP SE7 FIRST WATER LEVELQ _ ❑DESTRUCTION: 13OUT-0F.SERVICE WELL ❑ GEOPHYSICAL WELL it ❑ SOIL BORING 8 , r . INTENDED MITE TYPE OF ftLL7 CONSTgUCTION SPECIRCATIONS ❑ INDUSTRIAL ❑OPEN BOTTOM A 04A.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING r liF-DO D MESTFClPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASINO ❑ PUBUCIMUNICIPAL El DRIVEN O DEPTH OF GROUT SEAL SPECIFICATION R D IRRlQA730NlAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME ❑ MONITORING 6 GROUT 6FAL PUMPED: ❑Yet ❑No CONCRETE PEDESTAL BY DRILLER:❑Ya []No S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE S' PROPOSED CONSTRUCTIONIDRIWNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER f HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WDAKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR$UBZONTRACTING SIGNATURE CERTIFIES, THE FOLLOWING: 'I CERTIFY THAT IN THE PERFO CE OF HE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN%COMPEN TION WS OF, ` CALIFORNIA•' ANT MUST CALL 24 6 IN NCE FOR ALL REQUIRED 7PECTIONS AT 42091488-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X Title Dots PLOT PLAN(Draw to Seale)Soale '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 6. 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. L ... ...... .;. .,.. ...-... ... ...... ..... ... . ......... .......... ..... ........i ............ ....... ............ 1 C : ...... .......1 Z.. - .,.:, ....,., . . , ...: . .............................. ..................... .............. .......... ....... ...... .. ;r- e;I .. .. .. y 4 _� 4 ��a1CAlEBT' �.. J ...;.RECEIVE®... . -- -. r .. - Gam. ` .. ..,-. .. - �� 1 i C i ., .. .. H P IG Htw.�4JH�T: .)psi -._. ......... ...... .. DEPARTMENT USE ONLY APPficatien Accepted By Date n Area Grout Irn Fon BY Date Pump Impaction By Date �' �Q 97 Destruction Inpaoi Hen By i! Date M Comments: i ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED EC lCA6H RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE D o 76-0 9