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APPLICATION FOR WELLIPUMP PERMIT - SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES/ ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388,445 N.SAN JOAQUIN ST., STOCKTON,CA 95201.388 (209)468.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED (Complete In Trylieu5) 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 APNI S/O �_ H46APOL IA ST CITY $fe(_✓TC. + PARCEL SIZE/APNM OWNER'SNAME_SMEyCbA, RlJEL&PHFjml CESfER ADDRESS 010 E./'/A6A4yUA 570CKFb.,Cn gj-Wj PHONE CONTRACTOR 7-Pre4 TEGIf ADDRESS_(270 A!_go$"FRDIL✓I). UCN.SS/.SSS' PHONEI Q(Q-yY9-IeYGYt SUBCONTRACTOR 6JL3% /{rQL/YAT ADDRESS3,Z33 r1raneLA+-D sr, UCI PHONE 1916- TYPE OF WELLIPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL e ❑OTHER ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL! (TYPE OF PUMP) J 11 N_❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ` ❑OLrT-0E-SERVICE WELL ❑GEOPHYSICAL WELL S SOIL BORING /O 7D 3 FT R ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICA71ONS ❑INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING O ❑DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEELJPVC DIA.OF WELL CASING D ❑PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY _ GROUT BRAND NAME E ❑MONITORING GROUT SEAL PUMPED:❑Ya [IN. CONCRETE PEDESTAL BY DRILLER:❑Yr ❑Ne S APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE S PROPOSED CONSTRUCTIONIDPSLUNO METHOD:MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW 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'S COMPENSATION LAWS OF CALIFORNIA.-CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: -1 CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.' APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPPEECTIIOON$AT 120514!54422.COMPLETE DRAWING AT LOWER AREA PROVIDED. ',,I SIPmdX v"'IA The �J!L-. �Cn Data_y� - S� PLOT PUN(0—to Salve)Seale 'to O.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 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. Ff:.R 7 inP? It tb ?I DEPARTMENT USE ONLY 9 Application Accepted BY Data ` Ara Grout InPpeellon BY Date Pump Impaction By Date _! Dwtr ctlon Impaction BY Data C—.-,.: ACCOUNTING ONLY: AID! FAC,I R CODE) FEE INFO AMOUNT 11-ITTEO CHECK ASH RECEIVED BY DATE PER MITISERVICE REQUEST NUMNSIR INVOICE U 3 r U