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APPLICATION FOR WELLIPUMP PERMI SAN JOAaUIN COUNTY PUBLIC HEALTH SE6 ,ES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplsts in T41itats) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE ST 1 {ANDA jR DS �OF SAN JOAQUIN COUNTY PUBLIC HEALTH BE VICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDREBSlOR APNM_ , ,�LJLk 1 1 ! .1 CITY r 1 EL SIZEIAPNX OWNER'S NAME / / ADf,D/R/ES6 G7'1— L r PHO�NEE�#' CONTRACTOR D / �MD S r}I�J 12N WHONE+r F L, SUB CONTRACTOR ADDRESS LIC# PHONE Y TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL A ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-cONNE�C�T(}REPAIR ❑ VAPOR EXTRACTION LL# J 'AN.❑Repalr H.P. DEPTH PUMP SET 1217 FT. FIRST WATER LEVEL O [TYPE OF Pi \ "�-' – ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL f ❑ SOIL BORING 8 t, ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A C ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DiA.OF CONDUCTOR CASING D I DOMESTICtMVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELIPVC DIA.OF WELL CASING D S ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R I ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yes ❑No CONCRETE PEDESTAL BY DFYLLER:❑Yee ❑No S APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE - S PROPOSED CONSTRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HE{7£SY 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 i 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-0ONTRACTING 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 OF CALEFOLR,0.:– HEUC T�CA IN ADV ALL REQUIRED INS TIONS AT{2 J423. COMPLETE DRAWING AT LOWER AREA PRO DED. —11 Signed X 4 Title Dale PLAT PLAN(Drew to Scale)Scale 'to 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. TION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, 3. DIMENE40NEDD 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 PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. . . . 7` .. j.... .......................... . ........ .. � ,.. Pati i��F�� gt , .,. _ .. 3 hd'ti'1 t 1 Pd P11 ! 3 DEPARTMENT USE ONLY Application Accepted By Da Area f i Grout Inspection Sy Data Pump Inspection By - Oats Destruction Inspection By Dote 1 Comments: ACCOUNTING ONLY: AIDS FAC# PE CODES FEE INFO OUNT REMITTED EC !CASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE 0 5 - n LAa R