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APPLICATION FOR WELL)PUMP PER W P O L�l ` SAN JOAOUIN COUNTY PUBLIC HEALTH SkhviCES ENVIRONMENTAL HEALTH DIVISION SCAN14EW P 0 BOX 388, 445 N. SAN JOAOUIN ST., STOCKTON, CA 96201.388 (209) 468-3420 NOW-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ( rr'1� ;r Capleu in Triplicate) E APPLICATION 19 HERE BY MADE TO THE SAN JOADUkN COUNTY FOR A PERMIT TO CONSTRUCT ANpX)R INSTALL THE WORK DESCRIBED.THIS A 10 I E COMPLI CE WITH SAN I 4 JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND HE STANDARDS OF SANJC�QUI#COUNTY LIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. 7 b� ---- I JOB ADDRESS �.q-5 OR APR# CITY _ PARCEL 31ZE1APN9 €� OWNER'S NAME 6417 AlAll 446=pADDRESS,2 2.r,2i� // �,. �fl PHONE# ` CONTRACTORhl�Y=S /1)4\ 1 6�1/ z le ADDRESS..- & V/1, /�� t�I�,G�T_LICi 4d e,F-. r�-' � PHONE#•. `' :` e SUB CONTRACTOR ADDRESS LIC# PHONE# Ei TYPE OF WEL MP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONRORING WELL# ❑ OTHER 1 V INSTALLATION ❑WELL /SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLIF r K1 New❑Repair HIP.-/ DEPTH PUMP SET FT. FIRST WATER LEVEL O 1 (TYPE OF MP) ! _ T7 `.� ❑ OI1T-0E-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING 8 } �I ❑DESTRUCTION: f� INTENOEO USE TYPE Of WELL CONSTRUCTION SPECIFICATIONS A � I ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D t DOMESTICIPRIVATE 11 GRAVEL PACKISIZE TYPE OF CASING/STEEUPVC - DIA.OF WELL CASING D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION A a li ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E I ❑ MONRORING GROUT SEAL PUMPED; ❑Y. ❑No CONCRETE PEDESTAL BY DRILLER:❑yea ❑No S -I APPROX.DEPTH LOCKING CHESTER BOXISTOVE Pipe S�J I ,11 PROPOSED CONSTRUCTIONIDWI LING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(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 18 ISSUED,3 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF ii CALIFORNIA." T CA TCA 24 110 IN ADV NCE FOR REQU[R131 IN TIONS AT 12081 342=. COMPLETE DRAWING AT LOWER AREA PROVIDED. PPROVIDE,D... l� j '4 Slpnatl K - Tltlai 'fd �Data, ] r7 i ,I PLOT PLAN(Draw to Seale)Boole 'to l I 1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING 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. DLMENSIONED 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 PATFOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. k ... ..i ., :,...... .. ... '.T.' .. . SE DA .... .... I ... . Z 'I ... .. .... ..... ... ... .,., X. i ... rl Ir ., - ' Ix� k .. ... ...... ' fJll .,............ ;I ,�a°,i r,, i .. I61 t Tin rEi rI y'ii �i DEPARTMENT USE ONLY 0. I �i ApPllwtlon Accepted BY � Geta Ar" [•" S Grout Irnpoordon By Date Pump Impeatlon Si Data 2 ,f r Dst-6—Impeetlen By Date [I Comments: :L I ACCOUNTING ONLY: AID# FAC# I PE CODES FEE INFO AMOUNT REMITTED CHECK# ASH RECEIVED BY DATE PERMIT19ERVICE REQUEST NUMBEIt INVOICE � 3�� Il 3RFS l 5 i 4 I t ,I E