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APPLICATION FOR INELLIPUMP PERMIT v."AN JOAOUIN COUNTY PUBLIC HEALTH SERV e ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 ' (209) 468-3420 7"`,� n (� NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED /c�� a Re igo- (CompMb in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PEW ET TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT rTITLE. ^.CCHAPTER 9-1115. AND THE STANDARDS OF SAN JOAQUIN COUNTY PLISUC H[EEALLTTH—SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN# ( / V (T V, PLr (A ;e-.=, CrrY \�iX yCyQ"� PARCEL SIZEJAPN.07—/��09 a� OWNER'S NAME L��rt/JC--7;; f,nfJ�+ L�O(�P All My�J 0 A� ADDRESS �I �^� PHONE CONTRACTOR Y//(r-( fl CL l7 �A C. a ADDRES6 UCI ?92OVL PHONE SUB CONTRACTOR ADDRESS LIC# PHONE# TYPE OF WELUPUMP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAnt ❑ VAPOR EXTRACTION WELL# J S�t ❑N.0 Rap.,, H.P.I_ DEPTH PUMP SUZjg22R. FIRST WATER LEVEL L/4CCf: 0 TYPE OF PUMP) C1 OUT-OF-SERVICE WELL 0GEOPIV6ICAL WELL# ❑ 801E BORING B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D I$RIBUCWUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R LTJ• IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Ys ❑No CONCRETE PEDESTAL BY DRILLER:❑Y. [IN. S f APPROX.DEPTH I 07 LOCKING CHE6TER BOX/STOVE RPE S PROPOSED CONSTRUCTION/DWLNNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I 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 WOW FOR WHICH THIS PERMIT IS ISSUED,(SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMM)ATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'!COMP]) ATION LAWS OF CAUFORNIA.- CANT MUST C HOUR 1 ADVANCE FOR ALL REQUIRED INSPECTLQ&/a AT 120814803421. COMPLETE DRAWING AT LOWER AREA PROVIDED. SlerrE X � Title ��(� Date f ROT PLAN)Draw to Scala)Sul. 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUNE 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. 1 STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAL%S. ON THE PROPERTY OR ADJOINING PROPERTY. i I E�----� .� Leo PDe f < yvo y _- c it DEPARTMENT USE ONLY L� �/ Application Accepted By /n/ ® /l Area Z� 1 Y e Grout Inspection By Det Pump Inspection By Data (eT Tl 6 Dmt,.t,.n Imp«cion By Dat. Commenw ACCOUNTING ONLY: AID# FAL# PE CODES FEE INFO AMOUNT REMITTED HECK#/C SH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE 01Z7-U 7762 r ,