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n APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERllt.cS ENVIRONMENTAL HEALTH DIVISION P,O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 9SS201 12091466-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICOMP19t9 In Tirwkattil APPLICATION IS HERE BY MADE TO THE SAN JOA13UIN 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 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ' JOB ADDRESSIOR APNa1 a - � CITY PARCEL SIZEIAPN# S& OWNER'S NAME �tfy G -7 ADDRESS #0.. �T[+7 PHONE I-S&t CONTRACTORA�F"Q0C_ DLL#vLjD C? ADDRESS ^ 1JCI� }}I[. / I PHONE SUB CONTRACTOR ADDRESS I` '`, 3 '` LIC:/ PHONE# TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING.WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ,! -rO/2 -- ❑New RIYWvelr H.P. ff {TYPE OF PUMPI P DEPTH PIMP SET FT. FIRST WATER LEVEL O ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ BOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS a—1 �I❑ INDUSTRIAL 13 OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING a3 ICT MMESTICMMVATE ❑GRAVEL PACKISIZE TYPE OF CASINGIST£EIIPVC DIA.OF WELL CASING ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION p�� WRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yee [IN. CONCRETE PEDESTAL BY DRILLER:❑YM ❑Na { APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE S. PROPOSED CONSTRUCTIONIDRILLNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 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 At= 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 I f THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.. CONTRACTOR'B 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 091�j CALIFORNIA." THEA ANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS 7(209) 3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X e& Tills .,.... Date `L PLOT PLAN(Draw to Scale)Scala '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 S. LOCATION OF WELLS WTTNIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, ON THE PROPERTY OR ADJOINING PROPERTY. i.. -.` :...........:.....:....E.. '.. .. . u� ..G I la+�Vii. . .SUN .. ... .1 X99 .. .,.., ... L'L�UiVT .. # _. _ SAN,�C)/�C?L1, .. : ATH E ;. . : �` . H AL.HEAi TH D .. ... 5 F'(JB�IC } tN Ifl01VM�N IC)�V { . ............ ... . ... .... DEPARTMENT USE ONLY Appllcetlon Accepted By Date!✓_ Ates f J oe Grout Inspection By Data Pump Inspection By Destruction Intpeatlen BY Date Comments: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CNE !CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE I;� 030