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APPLICATION FOR WELLIPUMP PERM" SAN JOAQUIN COUNTY PUBLIC HEALTH SL ,CES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 (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 9-11,711 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# 9/y 7 T 6'f-3-;,C", [l CITY �S�Ci l,. •'J /PARCEL SIZE/APN# / OWNER'S NAME (I-e ADDRES$.�t a? I�JLG;f J)f�•J S to/1"A1.f PHONE I CONTRACTOR �7�j,i/'r /"-�'y ` / f f/a i p� ADDRESS ��1� �` ��/ l'{, ? [ �'C�f LIC# J •,Yfa PHONE,Y ? ., • s� SUBCONTRACTOR ADDRESS UC# PHONE# TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# j (TYPE OF PUMP) ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT--OF-SERVICE WELL 1-1GEOPHYSICAL WELL# ❑/ SOIL BORINGXg DESTRUCTION: / � (",1-4 / r" ir IF r 0 IN-\ Fes- C-, 1� I✓9, d'� �� INTENDED 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/STEEUPVC DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yea [IN. CONCRETE PEDESTAL BY DRILLER:❑Yes ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY 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, 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,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING 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 CALIFORNIA." T B►LICANT MUST C� LL UI3 4 HOURS IN ADVANCE FOR ALL REQUIRED INSPMTIONS AT 1209)468423. COMPLETE DRAWING AT LOWER AREA PROVIDED. \ L ) _ Signed X '�J Title Date �1?1 S PLOT PLAN (Drew to Scale)Scale "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 AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINFS 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. C ..:. _. i....... r _ ..ate'. a 'IN0V 2 I[ - r DEPARTMENT USE ONLY Application Accepted By Date Area Grout Inspection By j / Date Pump Inspection By Date Destruction Inspection By ! / Date Xao A�7 Comments: ACCOUNTING ONLY: AID# FAC# 7f GLIDES AMOUNT REMITTED CHEC ASN RECEIVED BY DATE PERMIT/SERVICE REQUEST Nl1M8E3t INVOICE 01-R 9-