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APPLICATION FOR WELLIPUMP PERMIT- JAN JOAQUIN COUNTY PUBLIC HEALTH SEI,,,,ES' ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON. CA 95201388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compieh In Triplientsl 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 SA JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-111 5.3 AND THE STANDARDS OF SAN JOAQUIN COUNTYPUBLICPUBLIC/HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSMR APN/ / vv(� /0 .4 /71�Q V CITY �/(/fGC WL`-�f�, -j --- P y��I�y yE0N g .45 OWNER'S NAME f1 CL C-d'r ADDRESS IOL.ZO S,A! �trt1� 4"," k'4 T� y�JDPHONEISd_3-?77-77/ / /�.KF H4,/ L 44 9,ys f CONTRACTOR -C I CCs^.Q✓`�l(�Q ADDRESS 7S-71 (nfJ/I/A11, Sk&CI 1, PHONE IF ZI.0 3 JV SUBCONTRACTOR C.T►' ! ADDRESS /,I'D _.�O W-l' I'I L1Cf PHONE!Jjr-113 Je TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONTFORINO WELL a ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J ❑New❑Repstr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 (TYPE OF PUMP) In,-,� ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL r BOIL BORING 61✓ g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION J. S (t--, DIA.OF CONDUCTOR CASING D ❑ DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEEIJPVC DIA.OF WELL CASING D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION /' R ❑ IRRIGATION/AG ©OTHER GROUT SEAL INSTALLED BY f-L r A GROUT BRAND NAME AV11411fQ E ❑ MONITORING GROUT SEAL PUMPED: ❑Yea CONCRETE PEDESTAL BY DRILLER:❑Yw ❑No S APPROX.DEPTH Z LOCKING CHESTER BOXISTOVE PIPE g PROPOSED CONBTRLICTIONMRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE NAT"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 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'8 HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES 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 OF CAUFORN^, HE AP ANT MUS/CALL 24 HOGRA 1N ADVAACZ F011 AE.I. 1N8SEC 170044 AT 4;1091 4633.323.�CC?APLET�DRAWING AT LOWER AREA PROVIDED. Signed X Title S % v' !//� ��f/-/ Date PLOT PLAN IDraw to Scale)Scala 'to 1. 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 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. '�[l�,,p+(/,ej DEPARTMENT USE ONLY (j Application Accepted BYI fs `��"�_ �' _` Date- hh- Arei©� Grout Impeetlon By ^' Dete PUMP InepeetlOn By Date Destruction Impaction By - { Date Comments: ACCOUN71NO ONLY: AIDM FAC,I PE CODES FEE INFO AMOUNT REMITTED CHE 1CASH RECEIVED BY DATE POWITISERVICE REQUEST NUMBER INVOICE