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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON,CA 9u.,T 388 (209) 4683420 NON-REFUNDABLE PERMIT EXPIRES t YEAR FROM DATE ISSUED IComplota in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNI + / / �] . [T. CIITY/�pl ��C.��`�Z7 ('+ PA1RCEL SIZE/APNI / ) F OWNER'S NAME 'e�y� / ADDRES�y/p Q,1 j I(/C4/7�1{1 1 /OC"/GI'/- RHONE I L412 T&�r7 CONTRACTOR � l-L[/Cl/"Pf' r(//!/.s�ADDREss- h7y ) ACf/Pony LICK 1�`1�f�"HHONE/ TZ SUBCONTRACTOR ADDRESS LIC/ RHONE s TYPE OF WELLIPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑ MONITORING WELL# ❑OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSSCONNECTREPAIR ❑VAPOR EXTRACTION WELL S ✓ ❑New❑Re k H.P. DEPTH PUMP SET FT. FIRST WATER LEVET 0 (TYPE Or PUMPI ❑OUT-OF-SERVICE WELL ❑GEOPHYSICAL WELL I ❑ 6011 BORING R 161 DESTRUCTION: INIENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.Of CONDUCTOR CASING D ❑DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC— DIA.OF WELL CASING D ❑PVRIIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BV GROUT BRAND NAME E ❑MONITORING GROUT SEAL PUMPED'❑Vee [IN. CONCRETE PEDESTAL BY DRILLER:Cl Yr ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTION/DRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER_ 114EREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WU-WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND,(� REGULATIONS OF THE SAN JOAQUIN COUNTY.HOME OWNER OR IICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"1 CERRIFY THAT IN THE PERFORMANCE OF THE WOW fOR WHICH�V THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S/TIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES\ THE FOLLOWING: "1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENa ATION LAWS OF CALIFORNIA.'/y,.'�^'o�''�C AArN MUST C LL 4 HO—iN ADVANCE FOR ALL REQUIRED INS/ TT1IOwNG AT 12")4603421. COMPLETE DRAWING AT LOWER AREA PROVIDED. It Slened% 7 PLOT PLAN IDT to 6u1e1 Scele 'to 1 NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED O 2. OUTLINE Of THE PROPERTY,GIVING DIMENSIONS ANO NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, ]. DIMENSIONED 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 1`11.11". yyipq —1 rT r.r: . c (V Ltd in /1 f�� NOV `1;0 199j nI iRtjr I-IF A,I DEPARTMENT USE ONLY Apollcetlon Accepted BY- 7'1E� `�'– ,///- Dete Aree GIOVI I-Pectlon By D.I.U _ P—o Impoctlon By Dete Dstnwtlon Impecti Cemmenn: ACCOUNTING ONLY: AID# FACS PE CODES AMOUNT REMITTED CHEECCj ASH RECEIVED BY DATE PFHMI7ISEAVICE REQUEST NUMBER INVOICE Ilvl dlsDds o Ii -I-,-M3 L -j Uolll`ld