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APPLICATION FOR WELLIPUMP PERMIT li SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 (209) 468-3420 NOWREFUNDABIE PERMIT EXPIRES I YEAR FROM DATE ISSUED lComPle + t APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRBEO.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 APNN L J490 Qnca CITY PARCEL SIZFJAPN# OWNER'S NAME! f _ ADDRESS T Ia.YYF •" PHONE# coNTRACTORi Q1�f ADDRESS j ucr �PRONE r� SUB CONTRACTOR ADDRESS LIC+# PHONE• TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL r J<� LtR N.❑Repair H.P. Ib m PE OF PUMP] DEPTH PUMP SET FT. FIRST WATER LEVEL O �• ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL R ❑ SOIL BORING 8 �� ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A _ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASING p S ❑ DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEELIPVC DIA.OF WELL CASING D �~ ❑ PUBUCIMUNK;IPAL ❑DRIVENDEPTH OF GROUT SEAL SPECIFICATpk A IFRIGATIONlAG OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORNG GROUT SEAL PUMPED: ❑Ys ❑No CONCRETE PEDESTAL BY DRILLFR;❑Yee [IN. S J APPROX.DEPTH LOCKING CHESTER BOXISTOVE RAPE S PROPOSED CONSTRUCTIONIMLUNG 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,ANO RULES AAD REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGFNT'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-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUEDr I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.• THE APPUC3NT MUST CALL NOUfii IN ADVANCE FOR ALL REQUIRED INSPECTION*AT(200)400-342?. COMPLETE DRAWING AT LOWER AREA PFIOLfVIDED. �1 SlOned Title OW l UO ! D.t• PLOT PLAN IDrew to Scale)Sulu'I.{9'1A 1lal 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTUNE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. y 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED 6. 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. cz5 PAYEN MAY 26 1998 SAN JOAQUIN CO.UN.TY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DVVISION