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APPLICATION FOR WELLIPUMP PERMIT 'AN JOAOUIN COUNTY PUBLIC HEALTH SERV; ENVIRONMENTAL HEALTH DIVISION <� P 0 BOX 388, 445 N. SAN JOAOUIN ST., STOCKTON, CA 55201.388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 9 YEAR FROM DATE ISSUED (Compkte 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 Wrm SAN JOAQUIN COUNTY DEVELOPMENT TITLE CHAPTER 9-1115.3 AND THE STANDARDS F 5 N JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR.APN# CITY PARCEL SIZE/APN# OWNER'S NAM njA ADDRESS PHONE# CONTRACTOR �j � - I r ?L'_—_ ADDRESS LfCNPHONE SUB CONTRACTOR .-z2,a ,-,,,ADDRESS LIC# PHONE# TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER "VINSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J G N.❑Repair H.P. f DEPTH PUMP SETFT. FIRST WATER LEVEL ILE O (TYPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B ` ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D $3�ROMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASING D ❑ (3S PVBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ' ❑ MRIGAT10N1AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E -s ❑ MONITORING GROUT SEAL PUMPED: ❑Yes ❑No CONCRETE PEDESTAL BY DRILLER:❑Yee ❑No S', APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE Sr�- PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER G 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 WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA. THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 4208)4683423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X TitleQAPZ::nDate PLOT PLAN(Draw to Scale)Scale 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 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. -. - ......,.. ....,_.,. - - i. .. .. .. .. .. ... ... .,:.. .. ... ..:. .. .. ... .. w :.. .. - .. -. _ IL�7` .V .> .. .. - 6 .. ., .,... ... - - -_. .. - - r rAV .. 1 r Pia 31 sC`'t-6�:`.�-it EY�lV FtiiivPy"iEMik! 4��r;; lYr,�arV; r DEPARTMENT USE ONLY Application Accepted By Date Area -Z- Grout inspection By Date Pump Inspection By 42 _ S Destruction Inspection By Date `. J Comments: f/a Lj ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED GHEC ASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE 3 415 �� I�q sem,