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APPLICATION FOR WELLIPUMP PERMIT N JOAQUIN COUNTY PUBLIC HEALTH SERVIC— ENVIRONMENTAL HEALTH DIVISION P 0 BOX 3B8, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) 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. JOB ADDRESS/OR APNNS /'l.1X ?SZ3OA/ CITY CA-i"I I/, �I PARCEL SIZE/APN#/IGI OWNER'S NAMEti:c - i�l ADDRESS ��11 �i7��n<' .le..z.f�lc "'/7 I�j{/ PHONE{Z!,'G) /�Z•"I/G�_ -YS5�ZJ. AeI,k2/ LI gl LICX PHONE+(0/G) CONTRACTOR •� � ADDRESSI ��✓� G �J Ge tr_Qe• SUB CONTRACTOR -� - �' / t� ADDRESS ALR LIC, W►{ 4PE 660- i4Z 3 Jr TYPE OF WELUPUMP: kt NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLX ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL X SOIL BORING 30 B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �j A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION ?� DIA.OF CONDUCTOR CASING O ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC f11��- DIA.OF WELL CASING ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL n SPECIFICATION {iLGt -f l' R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BV ';/Ib•� GROUT BRAND NAME E MONITORING GROUT SEAL PUMPED: rylYs ❑No CONCRETE PEDESTAL BY DRILLER:iRfYes []No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S Imo, PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER Llnt4 I HE9EBY 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 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: "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 V++r CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(209)4683423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X Title trFL.� �a � )_ LiY� Date PLOT PLAN (Draw to Sine)Scale '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. . .. .. .. .. I DEPARTMENT USE ONLY 2 Application Accepted By Date I L' J�q Ars _ Grout Inspection By Date Pump Inspection By Date Destruction Inspection B ,j Date Comments: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED HECK# ASH REC V D BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE � 29� .�o Sq•�o 4«�- I -3 q4 �