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APPLICATION FOR WELLIPUMP PERMIT • JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED p APPLICATION 18 HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT IANDr OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCEWITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3`" AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN/ {, A nn CITY S-Iec- OWNER'S NAME/fn/aa.� [J�- , I J / 'PARCEL SIZE/APNI�� p� nG�Q.^}^-PCL !i-ltAG4' P✓�f' ADDRESS (� . ,/ n` CONTRACTOR_ ////J / PHONE/y_7�z +-«�-SLL//L r Aft 1114 G� ADDRE96 / !,yp SUB CONTRACTOR UC/ 2L PHONE ADDRESS UCA'-_PHONE/��_ TYPE OF WELLIPUMP: d'.SI`VEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL R IJ INSTALLATION El WELL WELL SYSTEM REPAIR ❑ OTHER CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL ❑New❑Repalr H.P. DEPTH PUMP SET (TYPE OF PUMP) FT- FIRST WATER LEVEL ❑❑ OUT-OF-SERVICE WELL Cl GEOPHYSICAL GEOPHYSICAL WELL I SOIL BORING DEBTRVCTION: INTENDED USE TYPE OF WELL CONDTg1/C TION DPECIFICATIOND ❑ INDUSTRIAL [:10 OPEN BOTTOM / P�DOMEBTIC/PRIVATE 'm ��yy'eRAVEL PACK/SIZE DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING ❑ PUBLIC/MUNICIPAL ❑DRIVEN TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASING. DEPTH OF GROAT SEAL 7 I 6 ❑ IRRIGATION/AO ❑OTHER G ?SPECIFICATION GROUT SEAL INSTALLED BY GROUT BRAND NAME ❑ MONITORING t / �rj \ GROUT SEAL PUMPED:Q p,a ❑No CONCRETE PEDESTAL BY RILLEe APPROX.DEPTH_ J ,/V1� LOCKING CHESTER BOX/STOVE PPE�- PROPODED CONDTgUCTION/DPoWNG METHOD: MUD ROTARY _ 5 AIR ROTARY AUGER CABLE �__OTHER_ I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL A DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,BT AND RUlEB AND REGULATIONS OF THE SAN ALL NOT COUNTY, HOME OWNER T LICENSED AGENT'S SIGNATURE CERTIFIES THE FO LLOWINO:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WOR(FOR WHICH THIS PERMIT NG:ISSUED,I C 1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENDATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR CH 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 U"ONWORKMAN'SAC COMPdDAT10E CAWS OF CALIFORNIA.' T{/E APPUCAN7 MUTT CALL 24 HOURS IN ADVANCE FOR ALL REOUIgED INfPEC T10N$AT 1201)4q J42], COMPLETE DRAWING AT LOWER AREA PROVIDED. /V✓J!!C ff 8lpned X ` �YrL�IPHA TltlPLOT e 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING TH NPROPERTY(Draw to Soale)Sul. 'to 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 3. DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED EXPANSION OF SEWAGE DISPOSAL SYSTEMS. STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT. ON THE PROPERTY OR ADJOINING PROPERTY. .... ..............'.......' ... .... .. .. .. 1L .. .. .. .. ... ; .. .... A'N:F.- .. .. <.... ...... ...... ... .......... . _. ........> . .. -� -� .....<.......... .... .. .. Qom. leo .. k.. :. ....>......:....... .. .. .. .. .. .. .. .. .. .. .... t �.. ....... AR .... 1� PUBLIC hiv,;)AQUI. Q EP"IC[ AL7f•i ......:...........;...........>. . : �l�L}iEFILTN UIVI5fUr�— N VIRON.�� s ........ ...................... DEPARTMENT UDE ONLY .ppllealen Aeeepted By � Date Area rout Impaction By -1 Date✓ lU Pump Inapeetlon By eatructlon Irnpeotlon By Date ' Date ommenb: C (.(A A ACCOUNTING ONLY: AIDS FACR PE CODED FEE INFO AMOUNT REMITTED HEC /CASH RECEIVED By DATE PERMIT/SERVICE REQUEST NUMBER INVOICE