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� APPLICATION FOR WELI,IPUMP PERMIT AN JOAQUIN COUNTY PUBLIC HEALTH SERV ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAOUIN 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 OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APN# tJ 67- A41114L. CITY/��//�t L PARCEL SIZE/APNN OWNER'S NAME I, ^/I (� �+ � IJ�� ,a��'r ADDRESS_ �A I(K/ � /�. ''y PHONE N CONTRACTOR_ L'"T �� jV �, �•V C. ADDRESS ®� • �� T�/ LIC# S 6 1 PHONE# Z� 2 SUB CONTRACTOR ADDRESS LIC# PHONE# TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL#_ ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ❑ (TYPE OF PUMP) New 11Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING g ❑DESTRUCTION: INTENDED ENDED teat TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION �e DIA.OF CONDUCTOR CASING u D ElDOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC Pvr DIA.OF WELL CASING/ r 7'(��r�� ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL '�0 jCr—i P� SPECIFICATION t'�t'C p�a,:�1a-n!tJ g l❑t1 IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY C�� GROUT BRAND NAME OcS 1 l�:-tr��L', E M MONITORING GROUT SEAL PUMPED: 01. [IN. CONCRETE PEDESTAL BY DRILLER:td-7ee [IN. S APPROX.DEPTH �,. LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY � � AIR ROTARY AUGER CABLE OTHER 1 HE9EBY 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:"I 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." jIAEABPL1gAl1 N CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(2,09)4653423. COMPLETE DRAWING AT LOWER AREA PRO D. / 7 �l"I/ - Signed X Title � - �� G L ''"_- Date PLOT PLAN(Draw to Scale)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 5. 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......::.....,...K..........;......:.......;......:....... .. .. .. .. .. ... ....................... .'.......:.... .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. ........:.............:.......'. `......:..... .. ............... .. .. .. .. ............. .. ....r.......:.................................................... .. ......,: ......:.. ... ...............:.......;....................... ...;......... ; ; . . _ _ ................. ...;........ ...... ....... .. � r . ........... ... .... .......:.............:............:........ .....:.......................... ....................:......:.......:.......;......:.............. .... .... ... ..:.. ..:.. .. .......:. .......................:............. .. . . .. .. .. .. .. . .. .. . .. :.... .:.......:.. .. ... .... ...:.. . .: ....:.. .. s . .....;... :........ ..................... .:.. ..:.. .. ........... ...... .. .. .. ..... .......>...... .. . .. .. :: . .. ..............:.. . V. ........;.....................:.......:...... .. .. .. .. .. .. .. .. .. .. .. .. . .. . .. . ;......:...... .. .. `1 ......<......... .............. .: .. .. .. .. .. .. .. .. .. DEPARTMENT USE ONLY / h 9 ^(`/� Application Accepted By Date l v "� � /, � Area (/ I D Grout Inspection By Date Pump Inspection By Date Destruction Inspection By v^ y ,A y ,�"�� Date,/ D ,I R p Comments: ) ( I (� 1 d ) t b .�sWl6 f h '��t r 11� � ke d/e ACCOUNTING ONLY: AID# FAC# E PE CODES FEE INFO AMOUNT REMITTED HEC /CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE