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APPLICATION FOR WELL/PUMP PERMIT • SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201388 1209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete In Triplicate) APPLICATION 18 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 COUN7 PUBLIC H ALT"SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN# f7 o CITY G �"1 / PARCEL SIZEIAPNR I. f ,.•ter OWNER'S NAM \ SsQCLO:. t^Ou+—Pr,S' ADORESB J CONTRACTOR �� (� I I'l ADDRESS /.a//i^r LIC# Z Z PHONE SUB CONTRACTOR ADDRESS UC# PHONE# TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL IF J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) n,f1 O,,,O/1UT-OF-SERVICE WELL ❑( GEOPHYSICAL WELL#• ❑ SOIL BORING B �9WSTRUCTION: �T v' [� 1'I:k I ( C� 1 DK l ..w-qR Q�� i�— �� , "I it INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A0 ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING dD ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINO/STEEL/PVC DIA.OF WELL CASING Db ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME ES ❑ MONITORING GROUT SEAL PUMPED: ❑Yea [IN. CONCRETE PEDESTAL BY DRILLER:❑Yaa ❑No APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE PROPOSED CONSTAUCTIOWDRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER O 1 HE9E8Y 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: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'&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 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12091 4"9 S42]. COMPLETE DRAWING AT LOWER AREA PROVIDED. q` Slpned X (; - �' l..L�'�'F/ Tills )JkA 11, �QVh Dats�/ ��•—_l PLOT PLAN (Draw to Soslel Seale '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,OIIIVEWAYS,AND WALKS. ON THE PROPERTY OR ADJOINING PROPERTY. ...... .. ............ .. .... .....:... .: .. 1 .. .. ............... .. ............ ._....... .... ..1�: 1. .. r _:�` ........ .......... ................ .......... ..... ........ ......... ......... ...: 00 ..... : . �. ....... . ........ .. ;....._......;.. .. .. .. . . :.....................:................. . .. .. . .. .. ... ... .. .. .. . .. ... � Qra ... 7� .. .. : AFR � 3195/.. .. ....:... .. ..... ...... .. .. . .. . .. `;.All J4:.`l��Uay.f � .... ......:...... ....:.....:...... ......; .—.8,!'.IC.}HEA! Tf1..':i 1R'g1Gt �NVIROWOEIJAL HEALTH;01wSIt m! t DEPARTMENT USE ONLY Appllcstlon Accepted By Date & Area Grout Impaction By ' Date Pump Inspection By Date Destruction Impaction By�P�� p LG/C[�/�/ ' Date y� Comments: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED IEC #(CASH RECEIVED BY DATE PERMIT/&EAVICE REQUEST NUMBER INVOICE t4 3 o co 0 D 77 3 to