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- z - APPLICATION FOR WELLIPUMP PERMIT N JOAQUIN COUNTY PUBLIC HEALTH SERVIC ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED :(Complete i6 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 ADDRESSOR APNR f BQ �I�E. �� CITY��TC�y ... PARCEL StZEJAPN# "— OWNER'S NAME C-0 ADDRESS �J� '�j[JQ PHONE a241B CONTRACTOR valfq �/ < �C� .—ADDRESS a6 w C f11 4 LICK 4 0 Z 2.'7 PHONE A' LSO--O 2-G 4' SUB CONTRACTOR �� L gd L J LICN Z LD PHONE N41L 7 5- AODRESS V � TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLN ❑ OTHER ❑ INSTALLATION WELL SYSTEM REPAIR „❑ CROSSCONNECT REPAIR © VAPOR EXTRACTION WELL f J ❑New❑Rapelr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D (TYPE OF PUMP) 13 -0I OUT-0f-SERVICE WELL -❑ GEOPHYSICAL WELL 0 ❑ SOIL BORING g ISJ DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION'SPECIFICATIONS - A � JI I ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING p ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEELIPVCLr� DIA.OF WELL CASING 2 O ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL r SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME Fbx:rn E MONITORING GROUT SEAL PUMPED: ❑Yen ❑No CONCRETE PEDESTAL BY DRILLER:❑Yea ❑No S r APPROX.DEPTH s LOCKING CHESTER BOXISTOVE PIPE S PROPOSED CONSTRUCTIONMAILLING METHOD: MUD ROTARY AIR ROTARY AUGER 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 JOAGUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:-t 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.- THE APPLICANT MUST C 4 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTION$AT 1209E 468.34_2,3,.1 COMPLETE DRAWING AT LOWER AREA PROVIDED. Signed X Title- l71rz,�-�c�- G TTL-�'/S bate �..0 PLOT PLAN(Draw to Scala)'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 OUTUNF.S AND LOCATION OF ALL EXISTING AND PROPOSED 6. 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. .. .... .... ...... ... ..-. - - - r DEPARTMENT USE ONLY ��J Jf Date Application Accepted 8y - _ - zf q5 Area - Grout Inspection By Date Pump Inspection By Date G� I f I Dawtruetlon Inspection Date BY „-•� ' COmmema• 1N—" S �I i✓T l jl `-L/r�. J7_ 1 ACCOUNTING ONLY: AID# FACII 3`> X02" PE CODES FEE INFO AMOUNT REMITTED CHECKX/CASH RECEIVIED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE