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1 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 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\OFF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNO I v �✓'�Jg ) r�� I 1 11° CITY '5+' -PARCELSIZE/APNX L� ^}� OWNER'S NAME I G7<)_ G7<)S C� O I7 ti`' ADDRESS I�.t 1 I (7 1 ' V+ ,5(i1 1�Q,27/ PHONEZ0(01/q f CONTRACTOR ef�-/AM' WA—t`j�rA S��C 7` F.f ADDRESS H33 . Market G' UCX PHONE# Q GZo-33,70 SUBCONTRACTOR �:?'��—CI�1 .J�rly�q 1 'LS inR ADDRESS 14z ferry S UCxC94 Z�u pH0 NE#(516)1,�0"tF4�( TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑Now❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O (TYPE OF PUMP) y� ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL# ® SOIL BORING I B ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A\ ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D O ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER:❑Yea ❑No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING 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 JOAQUIN COUNTY. ME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHIC THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PER NS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: '1 CERTIFY THAT I�TE FO ANCE O THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OFCALIFORNIA.' AP CANTM�UST24 I_ VIN �INA IV NCE FOR ALL REQUIRED 8PECTIONS (20eD)466 23. COM E�DRnA11�NG AT LOWER AREA PR1O I1ED. Signed X ,(lV • v�" Title �� A � (� V Date r 1 f PLOT PLAN(Draw to Scalel 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. r - DEPARTMENT USE ONLY Application Accepted By Date ~ Ar Grout Inspection By Date Pump Inspection By Date Destruction Inspection By Date J`B en Commts: --' ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVEDBY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE iia) 5B `89, 'fo e11 !/-/(0-9 D4R5v