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LAPPLICATION FOR WELLIPUMP PERMIT 'r AN JOAQUIN COUNTY PUBLIC HEALTH SERVII ENVIRONMENTAL HEALTH DIVISION . i P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, C,A 95201.388 (209) 468-3420 l NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IF {Complete in Triplicate} !F i APPLICATION N HERE E MAGE TO THE SAN JOAQUIN COUNTY FOR A PERMIT 70 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. JOB ADDRESS/on AM _ '3 u]p . — �•p —CITY Stockton,F PARCEL SIZE/APN* OWNER'S NAME TTn i nn T ro ('n ADORES i ' —•. PHONE•21 3-722-6.. 8 7, CONTRACTOR ADDRESS !� 114-6-9-2-72Z PHONE,(-4J-5--8-5-4---9 4F SUB CONTRACTOR ADDRES6 �i :gyp LICN ONE A` „' 2Z I d TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL it IP ` ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR rl ❑ VAPOR EXTRACTION WELL# (TYPE OF DUMP) J; ❑New 11 Repair M.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p �7 ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL rT ,I ❑ SOIL BORING g {„I DESTRUCTION: I� f INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS rj 'I A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION C v p A t i SDIA.OF CONDUCTOR CASING D k ❑ DOMESTICMRIVATE ❑GRAVEL PACKISIZE TYPE OF CASING/STEEL/PVC �} i!� DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY }f GROUT BRAND NAME F ® MONITORING GROUT SEAL PUMPED: ❑Yee ❑No CONCRETE PEDESTAL BY DRILLER:❑Yea ❑No S APPROX.DEPTH LOCKING CHESTER BOXISTOVE P -II IPE S, PROPOSED CONSTRUCTIONIDRILUNO METHOD: MUD ROTARY AIR ROTARY AUGER IIIhCABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE.3WtTH 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:ill 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.' T E AP CAN UST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION$AT 12091 4693423. COMPLETE DRAWING AT LOWER AREA PROVIDED. ' Signed X Title �/� C^� it ,F Date ll 7 PLOT PLAN{Drew to Seale)Scale "to 1. N ES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED } 2. UNE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSEDi S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS. l ON THE PROPERTY OR ADJOINING PROPERTY. y' fr .. - . ...--................... ., ---- .. -. _ i .• �- h ....,. ....... ., -- 8EE.ATTACHED LOCATION MAP _ _ _ . . .... . .. t i . .:......... ..... .:.. - .. .. ...... .. .... . .... ................... .......- . . .... .... : .. . .p �k - _ ........ ..... ..... .......... �I DEPARTMENT USE ONLY �� Application Accepted BY - - - _ -_* +^-=—J- = D�e �' !/ / Area ✓y`" l� �. y i Grout Inspection By Date Pump Inspection By f Date I Destruction Inspection By '^ .f Date Comments: t Id IW Q C Y 1O r v- h b -elkilov ACCOUNTING ONLY: AID# FAC!/ r I PE CODES FEE INFO AMOUNT REMITTED CHECK*ICASH RECEIVED BY DATE .I PERMITISERVICE REQUEST NUMBER INVOICE J f� ;r