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APPLICATION FOR WELLIPUMP PERMIT sAN JOAQUIN COUNTY PUBLIC HEALTH SERVIM , ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388,445 N.SAN JOAQUIN ST.,STOCKTON,CA 95201.368 (209)468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompleto in TripBeau) 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 9-1115.3 and the Standards of San Joaquin County Public Health Services, Environmental Health Division. / �t� Job Address/or APN# //,2& S A',d(41 5T- city Af,3�/ G Par�cJeell�Size/APN# Owner's Name k- awr-< Address 6.3- ,-RR U 40- Z66/ /_�-T�/ _ Phone# / ^C9 Contrecto ��/ u :/.CAddressf60 u-`AW--6 4-11 -4A Lic# Phone #9$e, C Y tF/7 �'{ fid' /,, �70- Sub rG. Sub ContractorZf`/1C a'�X OlG'lLC TU'+�- Address-iv/ Lic#G11� /c�Q Phone# � X-77 /�,%Y fi�Ttr! �cl't ��Jam/1 TYPE OF WELL/PUMP: ❑ NEW WELL [I REPLACEMENT WELL ❑ MONITORING WELL # [3 OTHER El DESTRUCTION El OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL # P/SOIL BORING I ❑ INSTALLATION [I WELL SYSTEM REPAIR [I CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL # ❑ New ❑ Repair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL (TYPE OF PUMP) INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS [I INDUSTRIAL [I OPEN BOTTOM DIA. OF WELL EXCAVATION f�y/ DIA. OF CONDUCTOR CASING ❑ DOMESTIC/PRIVATE ❑ GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVCnnN/f1 DIA. OF WELL CASING �fQ [I PUBLIC/MUNICIPAL [I DRIVEN DEPTH OF GROUT SEArrttL/ L 7SPECIFICATION r �f_�,. ,�-- ❑I IRRIGATION/AG [I OTHER GROUT SEAL INSTALLED BYE`//Y` GROUT BRAND NAME �G'/N1413 E! MONITORING / GROUT SEAL PIMPED: ❑ Yes d.o CONCRETE PEDESTAL BY DRILLER: [I Yes ❑ No APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE PROPOSED CONSTRUCTIONIORILLING METHOD: MUD ROTARY_AIR ROTARY_AUGER4 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: m1 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: " 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." THEAPPLICANT MUST CALL IN OV R All REOUI D INSPECTIONS AT(208)488.3423. Complete drawing at lower area provided. Signed X Title ��ti41 PLOT PLAN (Draw to Scale) Scale " to 1. Names of streets or roads nearest to or bounding the property. 4. Location of house sewage disposal system or 2. Outline of the property, giving dimensions and North direction. proposed expansion of sewage disposal systems. 3. Dimensioned outlines and Location of all existing and proposed 5. Location of wells within radius of 150 ft. on structures, including covered areas such as patios, driveways, the property or adjoining property. and walks. /t DEPARTMENT USE ONLY Application Accepted By tr, Date 5 � C Area / /fix , Grout Inspection By �L"" Date&//& Puny Inspection By Date Ll Destruction Inspection By Date Comments: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITISERVICE REQUEST NUMBER INVOICE °LS lole3s