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APPLICATION FOR WELLIPUMP PERM' AN JOAQUIN COUNTY PUBLIC HEALTH SEr:iCES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 1 j 7 JA- 3S I) a I209I 468-3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS 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 OtVISIONy ,S ) f + /'Ffw. Dy.--lec'• c1i / .�f"s,r�°/r i - y�.37`s'C JOB ADDRESSIOR APN# G- Z- Oma"�aa� CITY �[ �ljr"'� PARCEL SIZEIAPN#_ 7, -).F OWNER'S NAME �r.�,�.�_-- f/,r��ytN.,vJ�,�P_ ADDRESS 2Z3-2z 117,le'- rQ G. 41 PHONE# �'s/-ZVe Gl CONTRACTOR O E ADDRESS LiC# PHONE# SUR CONTRACTOR ADDRESS LIC# PHONE# TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER �--'•--r- ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECTREPAIR ❑ VAPOR EXTRACTION WELL# ,! ❑New❑Repair H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL if ❑ SOIL BORING g ❑ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DEA.OF WELL EXCAVATION DIA.Of CONDUCTOR CASING Q ❑ DOMESTICfPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELIPVC DIA-OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION `j,��J ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E" ❑ MONITORING GROUT SEAL PUMPED: ❑Ye. ❑No CONCRETE PEDESTAL BY OPIILLFR!❑Ye. [IN. 5('I, APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE PROPOSED CONSTRLICTIONIDRIWNG 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 ANO - 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,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'e COMPENSATION LAWS OF CALIFORNIA.' THE/APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INIPECTIONS AT f209 �I � r 4603423 . COMPLETE DRAWNG AT LOWER AREA PROVIDED. Signed 'E -Title / ^ AW Cfr+ r OeteQrC Z i!� 7 T PLOT PLAN(Draw to Sc.iel Somte ton/��// -L 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOU SCIa!'�fI� LYSTEM OR PROPOSED .. 2- OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION- EXPANSION OF SEW DIm,SyFJyL6, -� 3. DIMENSIONED OIFFLINFS AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELL Itf I E HUNDRED FIFTY F'T, STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OININ r SAN JOAQUIN WLINIY hICA�Thi t F�1,.. .. . ENVIRONMENTAL HEALTH DIVISION CIS F- r I . ' NJ � M a o ti i N onR f �. DEPARTMENT USE ONLY Application Aecepted By C f Date Arse, Grout Inspection By Date Pump Inspectlon By Oestruction Irnpectlon By Date Comments: / ! Y ACCOUNTING ONLY: AID# FAC# C PP CODES FEE INFO AMOUNT REMITTED CHEC #!CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE