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APPLICATION FOR VYELLrPUMP PERMIT II f SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445.N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 (209) 468.3420 E NDN-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED COPY a EI (Complete in Triplicate) f 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 COMPUANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB -7ADDRESSlOR APN2�1 CITY /� PARCEL SIZE/APN# �y k IEEI OWNER'S NAME / ,I g'r_ ADDRESS d+�+y� ^p` 1� •11 �r PpHO�NE R �P ` I I CONTRACTORT"LJ j¢_./ l�,y4 dZ t l I iI'�_//. ADDRESS'Pn-, .11�I,?r �� lUCIG�',�.VHONE# r,F�`3 I—) �I SUB CONTRACTOR ADDRESS LIC# PHONE# I EI TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL '❑ MONITORING WELL# 0 OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR r❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J i ❑New 0 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ITYP£OF PUMP) ❑ OUT.OF•SERVtCE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING B EI ,r ra ` � t' DESTRUCTION: CJ P iJ 01, 17 INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACY/SIZE TYPE OF CASINGISTEELJPVC DIA.OF WELL CASING D 1 kI ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R I�` ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yee ❑No CONCRETE PEDESTAL BY DRILLFR:❑Y® ❑No S ki APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S C> 'I PROPOSED CONSTRUCTIONIDRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I I it 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,I SHAH 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 O CALIFORNIA.' THE APPLICANT M 8T 24 HOURS 19-ADVANCE FOR ALL REQUIRED INSPECTIONS A 12021 4!8.3423. COMPLETE DRAWING AT LOWER AREA PHOVI Slp ! r /'I "� N Title Date �. l ! PLOT PLAN(Drew to Scale!Scale 'to + i 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED f 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS, l 3. DIMENSIONED OUTLINES AND LOCATION OF'ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. k STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. .......... :.,., ... .. ., .... I ' PAYMENT ..... . 9 SAN JOA PFjRL. :. ..,.... ..,. .. ptJr pp�� .. .. .... ., illi R�`IIY4 [L'Hili LIv Fri AL'Hiy.As T. i Sl�n EPAl4T—M USEEONLY EI Application Accepted By Date A,es� Grout Inspection By Da Pump Inspection By Data f� Ontructicn Inspection By Date ,I Comments: 1 ACCOUNTING ONLY: AID# FAC# —}✓w(C r� Q y y�p� PE CODES FEE INFO AMOUNT REMITTED EC !CASH RECEIVED BY DATE PERMITISETRVICE REQUEST NUMBER INVOICE I 'a I l� i I I�