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: APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES 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 (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 8-111 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ,JOB ADDRESSOR APNN CITY PARCEL S12E/APNt / 'T "OWNER'S NAME ADDRESS . PHONE ADDR6SPI� LCN PHONE O•NE N,CONTRACTOR _X45 7gl —S CONTRACTOR /� �.�' ADDRESS LIC# PHONE N � ,TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL l ❑ OTHER ❑ INSTALLATIONYELL SY TEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION 1WELLN ✓ Jar�h ❑N—13Repair H.P.= DEPTH PUMP SET FT. FIRST WATER LEVEL Y) / O CIYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL N ❑ SOIL BORING 8 ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A `❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING 0 ErDOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEEL/PVC DIA.OF WELL CASING D ❑ PUBUC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R C ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E C3MONTrORING GROUT SEAL PUMPED: ❑Y« ❑No CONCRETE PEDESTAL BY DRILLER:Ely- ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER �I I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORLNNAFICES,STATE LAWS.AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT M THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMP04SATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES C THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OFA CALIFORNIA.' APP'UC ANT C�ALL 24 NOl1RS IN ADVANCE FOR ALL REQUIRED INSP TIfONi AT(2091 4Q83423. COMPLETE DRAWING AT LOWER AREA ViD Signed X Tit.. DSte PLOT PLAN(Drew to ScoW Book 'to I. 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. STRUCTURFS,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WAI KS. oN THF PROPERTY OR ADJOWING PROPERTY. ONO .... ..-.. .. .: .. .. i W ... . .. ........ ... .. .... , ...... .. k .. t. ........... RJ o, /. t : : : aws