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APPLICATION FOR WELLIPUMP PERMIT O SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95M-W (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES I YEAR FROM DATE ISSUED ORIGINAL ,; (Campiete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANO/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WrTH SAN JOAQUIN COUNTY DEVELOPMQgjrr CHAPTE 8-111 .3 D THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. cc ,yam, Z•;) % S JOB ADDRESOR AAPPN. t✓✓ PARCEL SIZE/APNI ��-'l.1J i_ �, Cj OWNER'S NAME ! t)If�� ADDRESS CONTRACTOR Z ti� II�1- J2 Z REss__}1 rddl l CU ucr ShL '�( _ - I V 6�i PHONE I(S'n. S SUBCONTRACTOR �.yC C 1 V U W1 � (it�Q.' ✓L ADDRESS UCI S I ?2 1:;, PHONE `{ '�'" —1 1 Z REPLACEMENT WELL l LVJ MONITORING WELL� 1 ❑ OTHER TYPE OF WELLIPUMP: ❑ NEW WELL ❑ ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR r r ,t, ❑ VAPOR EXTRACTION WELL l ,gyp-g5 � ❑New❑Repair H.P. DEPTH PUMP SET FT. 7 r (TYPE OF PUMP) FIRST WATER LEVEL p K� - 1 J ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL I ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL '�`r Li CONSTRUCTION SPECIFICATIONS rl ` ❑ INDUSTRIAL ❑7(�tf7 BOTTOM Iti/); rI}r r.� DIA.OF WELL EXCAVATION_i( NJ;� DIA.OF CONDUCTOR CASING p ❑ DOMESTIC/PRIVATE ( ti L PACK/SIZE '>tl"I(k / TYPE OF CASING/STEEL�PV�I 4'I� �C deli kt I( U DIA.OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL G�b' � _ SPECIFICATION L y q ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E MONITORING I GROUT SEAL PUMPED: 5(Yea No /r�'L CONCRETE PEDESTAL BY DRILLER: Yee ❑Ne S APPROX.DEPTH-�11,IA v'• %Z-•d - I�t'r'�\ 5 LOCKING CHESTER BOX/STOVE PIPE - t T EIC rZa+ec� (M yN 1'YlL.L'0 S PROPOSED CONSTRUCTION/DMLLING 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. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH [HIS 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 18 ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' THE APPLICANT MUST CALL 24 8 IN ADVANCE X EWA ED INSPECTIONS AT(200) 3WI 4" 423, COMPLETE DRAWING AT LOWER AREA PROVIDED. c Signed X M /l,/IV11 �Ul !/V 6 V7 ee-e-- P Data I PLOT PIAN (Draw to Scala) Scale to 12 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY, 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROROSED ---- 2. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION. EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3. DIMENSIONED OUTLINFS 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............:.. ...... ..:............ ..,....... _ ...:.._ .. .. .. .. .. .. .. �� .... ..........:......i. -/1'iV 11[y .. .. \ �...-.:......i.. ..i. .........i....... ..:. 1. DEPARTMENT USE ONLY Application Accepted By Grout Impectlon By Date Pump Inspection By Date Daetructlon Impaction By l Date Commenu: Q \ D 15 gs t qs VOG/ • •/ •FQ -L-�" - ex — ACCOUNTING ONLY: AID# FACS PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE er