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APPLICATION FOR WELLIPUMP PERMIT " SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201-388 1209► 468.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Compi$t$ In Triplie$t$) 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 8-1 11 5.3 AND THE �STANDARDS OF SAN JOAQUIN COU PUBLIC HEALTH SERVICER,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN/ r �O CITY I PARCEL SIZE/APN/ OWNER'S NAME -jth �� xx ADDREBB 1 � iIq�, �A171 PHONE/ CONTRACTOR e) 7 � ✓] -D(�E88 UCI� 'tel PHONE I c SUB CONTRACTORLl kA ADDRESS "—/ �E PHONE TYPE OF WE MP; ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL IF ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTIO1 WELL/ 1 New❑Repolr H.P. DEPTH PUMP BET�FT. FIRST WATER LEVEL Kl --� ffyA OF PUMP) O ❑ OUT-OF-SERVICE WELL ❑ OEOPHYSICAL WELL R ❑ SOIL BORING ❑DESTRUCTION: INTENDED USF TYPE OF WELL CON$TRL/CTION SPECIFICATIONS �) A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING KDOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASINO j* ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME Et Cl MONITORING GROUT SEAL PUMPED: ❑Yee ❑No CONCRETE PEDESTAL BY DRILLER:❑Yee ❑No Siturt APPROX.DEPTH LOCKING CHESTER BOX/STOVE POPE S4 PROPOSED CONSTRUCTIONMRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER JJ I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE BAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTINO SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MU$ C 24 HOURS IN ADVANCE FOR ALL REGLARED IN$ TIONS AT 12001400-3422. COMPLETE DRAWING AT LOWER AMA PROVIDED. 8lpned^-1-1� 0 Tltle 1 �-; Dae PLOT PLAN(Drew to Scale)Snele 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LO TION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY.GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINER 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,.... .....:._ .; : _._..... .. ...:'.._. .. :_...; i_ _.. -......:.. __ . r ..... :.....: ... .... . . .. . ....: ... .... ... f ::-; r _.. . .... ...... ...........; ... ,.. t� 1 ti 199E ............. v nUMML! rr; DEPARTMENT USE ONLY �.�:w:•:Jit-!rV APPNoatlon Accepted By Date S Arse Grout Inspectlon BY Oete Pump Inspection By Dale V, Deetructlon Inspection By - Dae Comments. ACCOUNTING ONLY: AID/ FAC/ PE CODES FEE INFO AMOUNT REMITTED CHECK CASH RECEIVED BY DATE / PERMIT,$ER/VIICE REQUEST NUMBER INVOICE