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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES _ ENVIRONMENTAL HEALTH DIVISION ri l i i_I i 1995 P 0 BOX 388, 44b N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 (209)-460-3420 ENVIRONMENMAL HEALTH NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED C(OPY PERMITISEWCES (C6mpiate.la 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 6AN JOAQUIN COUNTY DEVELOP ENT TI LE,CHAPTER 9-1 15.3 ACID THE ST A S OF SAN JOAQUIN COU PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSfOR APNN - CITY PARCEL SIZFJAPN#-----�'� - r OWNER'S NAME ADDRESS q PHONE N CONTRACTOR n C ADDRESS l LIC PHONE,I I /! SUB CONTRACTOR `1— ADDRESS �� LICI PHONE R — TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL N ❑OTHER - WlpisTALLATION' ❑ WELL /(STEM REPAIR ❑ CROSS-CONNE T REPAIR ❑VAPOR EXTRACTION WELL f J ❑N424 pa)r'N H.P.T�s DEPTH PUMP SET FT. FIRST WATER LEVEL,^� O {TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING A tri- DESTRUCTION: INTENDED UBE TYPE OF WELL CONSTRUCTION SPECIFICATIGNS A 13 INDUSTRIAL ❑OPEN E10TTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING 0 }1DQMESTIC/PRIVATE.�r ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELJPVC DIA.OF WELL CASING 0 l_ /D PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION A ❑ IRRIGATIONlAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E r 0 MONITORING GROUT SEAL PUMPED: ❑Yee ❑No CONCRETE PEDESTAL BY DRILLI'M❑Y— ❑No S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE g PROPOSED CONSTRUCTIONIDRIWNG 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 FORWHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'19 COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRINO OR SUB-CONTRACTING SIGNATURE CERTIFIES ' THE FOLLG O; 1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CAUFORNI APPLJCAN7 MUST CALL 24 HO IN ADYANCE FOR ALL REQUIRED INSPECTIONS AT 12WI 468.3423. COMPLETE DRAWING AT LOWER AREA PRO ID C� 616ned% Title Date i PLOT PLA IDraw to Sealal Scala '!o 7. 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 5. 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. .....r.. ..... .. ,... L... ,.... ....r - I . �� .. .. . ..... . ...... .... N AYM9 RFV Qr . AUG G 7. 1995 v t1 �NLfRC.V�fE l v .::.. TAIL hEA rN bfVl DEPARTMENT USE ONLY Appllcatlon Accepted BY Date Arm k Grout Irupectlon By Date 9 S l Pump irnPectlen BY Data�� -- . Comment: ACCOUNTING ONLY: AIDX FAC,P PE CODES FEE INFO AMOUNT REMITTED CHEC ICASH RECEIVED BY DATE PERMIYISERVLCE REQUEST NUMBER INVOICE