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I APPLICATION FOR WELLIPUMP PERMIT ,`��-T .AN JOAOUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388. 384 EAST WEBER AVENUE, STOCKTON, CA 95201 (208) 488.3420 %,;uply NON REFUNDABLE PERMIT EXPIRES 1 YEAR FRO N DATE ISSUED IComplats In Trolleatrl APPLICATION IS HERE BY MAGE 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 8-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEA H SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSMA APN#-06:2 ® CITY J D L fr+ PARCEL SIZF/APN# OWNER'S NAME�LCI T1�,��—w,lji�r r ADDRESS [) p �, ✓e PH NE a CONTRACTOR __. /F!Qs' �- �_ADDRE86 �✓ GCN ��OpHow/ 3`f jzzg 1 .SUBCONTRACTOR ADDRESS UC#— PHONE# TYPE OF WELMMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL ' ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ OTHER ' ❑N— ❑ CR688�CONNECT REPAIR ❑ VAPOR EXTRACTION WELL! J (!�_N 9Repalr H.P.— DEPTH PUMP SET —FT.OF PUMP) FT. FIRST WATER LEVEL O ` '❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B, ❑ DESTRUCTION: iz.N i IN ENOFb USF TYPE OF WELL CONSTRUCTION SPECIFICATIONS ❑ INDUSTRIAL OPEN BOTTOMA DIA,OF WELL EXCAVATION ❑ DOMESTIC/PRIVATE 13 GRAVEL OF CONDUCTOR CASING Dr)�6AAVEL PACK1812F _TYPE OF CASINGISTEELlPVC - ' ❑ PUBUC/MUNICIPAL ❑DRIVEN CIA.OF WELL CASINO D' fidDEPTH OF GROUT 8EAL SPECIFICATION `r 3 MONITOIRRIOATRING OTHER GROUT SEAL INSTALLED BY r 1' ❑ MONITORING GROUT BRAND NAME . GROUT SEAL PUMPEDYae ❑Ne S^ I APPROX.DEPTH__. 12 : [3CONCRETE P'EOESTAL BY DRILLER:❑Yr ❑No- LOCKING CHESTER Bp7V8TOVE PIPE 1V PROPOSED CONSTRUCTIONaMLUNO METHOD: MUD ROTARYS AIR ROTARY AUGER CABLE OTHER [I I HEgEBY 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 AND 1 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 FOP WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 11 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE C NT MUST CALL HOURS IN ADVANCE FOR ALL REQUIRED INSPEiCTIONs AT 12001 -*423 COMPLETE DRAWING AT LOWER AREA PROVFDE r I Slpned X Tltl* / - ...( � f Date Z PLOT PLAN(Draw to S"oj Saab k I. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING THE PROPERTY, t to 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. #• LOCATION'OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS. STRUCTURES,MCLUDIN6 COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. S• LOCATION OF WELLS WITHIN RADIUS Of ONE HUNDRED FIFTY FT. ON THE PROPERTY OR ADJOINING PROPERTY. 44 40 n I.J 13C i J1 A�e ... s 7 : t � PAYMUY r ... 99 .. SAN lQAQj111v.GClU 1V�Y -t)f D!V _ C VlRply LIC F{_AtTH SE�V1C�ti MENTAL HEALTH ISIU�... ............. DEPARTMENT USE ONLY Appliwtien Accepted By bete Area / 7 Great Inspeatlon By Date f Pump InapaaUen By beetructien Inapaotlen Sy - Date Date ' Cemmenta: r N ACCOUNTING ONLY: AIDI FAC# PE CODES F AMOUNT REMITTED CHECK#1CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE � �i�' y