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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SER- C'S ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (209) 468.3420 \ NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED n L�� �E �t'�' (Complete 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 WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/ORCAP(NNN. % �f �/� [(f E/ �I CITYl'� (ft,�/1�L<-- PARCEL SIZE/APNN OWNER'S NAME S YC1 lJ`_ -/ � f__G� ADDRESS ✓VL PHONE x CONTRACTOR—w'— L =tic ADDRES D/Z IJC#.?220 _PHONE X C .- SUB CONTRACTOR ADDRESS UCI PHONE X TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL N ❑ OTHER (; n ❑ INSTALLATION C1 WELLS TEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLY J C�"{/// ❑ Newp Repair H.P. DEPTH PUMP SE�FT. FIRST WATER LEVEL —3e) O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL X ❑ SOIL BORING B ❑DESTRUCTION: C INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D �rJ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R� ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: C1Yes [IN. CONCRETE PEDESTAL BY DRILLER:❑Ys []No S APPROX.DEPTH / S LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILUNG 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 WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.- 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 COMPEN TION LAWS OF CALIFOR . THE PPUCANT MUST CALL 24 HO ADV E FOR ALL REQUIRED INSPEC TIjO�N/i AT 12oa1 4!83423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X Title p'" Date PLOT PLAN (Draw to Scale)Scale '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 6. 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. l`fz �y ... ..... ..... .. .. ............ .. . . .. ......... .. ... _n \' ........ ....................... .... . .. .. DEc...1. X99 c . QAQ- EJf3 IjEA .. . MEN L ,H ............. Sry . AL HtA! DEPARTMENT USE ONLY ' Application Accepted By r 1-11D;te Area y Grout Inspection By [e Pump Inspection By li Date Destruction Inspection By Date Comments•. ACCOUNTING ONLY: AIDN FACX iPE CODES FEE INFO AMOUNT REMITTED ECK CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE