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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERWS ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388t 304 EAST WEBER AVENUE, STOCKTON, CA VISM-388 1209) 469.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Compton IR TFIpHNN) APPLICATION IB HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANOIOR INSTALL THE WORK DESCRIBED.THIS APPUCAT16N IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAFFER 9-111 5,3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH OPASION. JOB ADDRESSOR APN/ 1 CITY �a� PARCEL SIZEIAPN/ OWNER'S NAME10 ADDRE8 O L,., ONEs.35D 4q/? CONTRACTOR ARE .._.._ - _ _ ADDRESS IF0,3 uCI a PHONE/9'4-t -0a76 SUBCONTRACTOR �/ ADDR 68,q Nt�12.t• � -7 / uC� PHONE 7x7/ , yNE' Tse TYPE OF WELLIPUMP; 9 W WELL ❑ REPLACEMENT WELL Ek-a-NITORINO WELL ❑ OTHER - 13 (INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL! RYPE OF PUMP► b New 13Reperr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL__,20 p ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELLS ❑ SOIL BORING ❑DESTRUCTION: INTENDED USE TYPE Of WELL CONSTRUCTION*PECIgCAT10N* A ❑ INDUSTRIAL 0� OPEN BOTTO��MII DIA.OF WELL EXCAVATION_ DIA.OF CONDUCTOR CASING / D ❑ DOMESTICIPRIVATE PGRAVEL PACy!(r7� 10• :P- TYPE Of CASINGISTEEt2!7 DIA.OF WELL CASING K D 'I i ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL [ W+ f SPECIFICATION R 11 IR' [2 GRRIGATIONIAG [3 OTHER GROUT SEAL INSTALLED BY D�Z+v Y LJ?�' GROUT BRAND NAME F Fl`MONITORING OUT SEAL PUMpEO: Yae ❑No CONCRETE PEDESTAL BY DRILLER:GY/r []No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE POPE g t PROPOSED CONSTRUCTIONIORILUNO METHOD: MUD ROTARY AIR ROTARY AUGER SABLE OTHER I I HMSY 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: '1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK 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 IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'{COMPENSATION LAWS OF CALIFORNIA.' THE:APPU ANT MUST CALL 21 NOW IN ADVANCE FOR ALL REQUIRES IN SPECT ION*/AT 1204411466-3422. COMPLETE DRAWING AT LOWER AREA PROVIDED.Signed Signed XL ! _."�-^ra/`itl/� ....._ Title l.� t- V -C�{a}V �.� Gate S ZS—,F/<) PLOT PLAN(Drew to Sasiol Slide "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 G. 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 °.. .. .... . _ F i4v - : : ......... Z .. :....:....:.......;..................:.. ..:..... .... , DEPARTMENT USE ONLY 7 � r Application Accepted BY—4, oe� ......._ Date C.� Ar &�/0 ( v Grout Impaction BY Date Pump Inspection By Date Oestruetlon Inspection By Date ' Comments: ACCOUNTING ONLY: AID# FACS 35+,.O tl PE CODES FEE INFO AMOUNT REMITTED C C 1CA8H RECEIVED BY GATE PERMITISERVICR REQUEST NUMBER INVOICE