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' APPLICATION FOR WELLIPUMP PERMIT 1, � N JOAQUIN COUNTY PUBLIC HEALTH SERVt - ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 446 N. SAN JOAQUIN ST., STOUTON, CA 56201.388 P (209) 468.3420 C NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICompiete 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 9-111 S,3 ANDD/THE STAAND�yA�RDS.OF SJOAg0 Ii�C NTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH D SION.. •� JOB ADDRESS/OR APN; AJ 0_l\>f / � t-�1 �tfJ� ClTY1(�: ESC _ PARCEL SIZEfAPNM OWNER'S NAMEC i Of* C-SCA ,01i C MQA4 �W Vj ADDRESS 1 4 W/� 'tel�j E ' 1.�'N .7Za (�.� ) ,.y �_. ��LS �p` ----------�s�� PHONE A�P7��jYI��JO CONTRACTOR IQ ti�, - ADDRESS---- rr^'. �tt, F��-i��L_ ��✓Lf l � u/c�• y J�7�Pr ojE 17 r��Y�'yj SUBCONTRACTOR S L'C1 N Ls AD0R4 ,7f'!lY\. 1 �.J�+ C;� �F Z26 ONE ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL; ❑ OTHER 1 TYPE OF WELIJPUMP: i ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL; J� ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O 1 (TYPE OF PUMP) ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL; SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA,OF CONDUCTOR CASING A 01 ❑ DOMESTICIPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEEUPVC DIA.OF WELL CASING p ❑ PUBUCIMUNICIPAL ❑DRIVEN DEPTH OF GROUT6-AL SPECIFICATION R ❑ IRRIGATIONIAG THER GROUT SEAL INSTALLED BY GROUT BRAND NAME E' MONITORING roti I POP-l NC�?,�;. G'Iv'1_ GROUT SEAL PUMPED: ❑Yes ❑No CONCRETE PEDESTAL BY DRILLE Yea ❑Ne S' APPROX.DEPTH. I LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CoH TTRUCTIONIDRIWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I, 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 ANI) 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'S COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'IjqWIFY THA '-HE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED.I SHALL EMPLOY PERSONS SUBJECT TO IIVORKMAWS COMPENSATION LAWS OF CALIFO T 7U 24 HOURS IN ADVjkNCF FOR REQUIRED INSPECsTIONE AT/4200 469E-3423./COMPLETE DRAWING AT LOWER AREA PPR`ROMDED. Signed X ' TIxIaP//�/& '�` f''F Date ✓ { 1K f PLOT PLAN(Draw to Scale)Scale 'to r 1. NAMES OF E-1S OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED j 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. I i .. .. .. .. .. .... . .. .. :.. ..:.. ..: .......i......:.......:........... .. - .. .. .. .. .. ..... ......i .....-..,.-1..............:..............i.............: .. .. .. .. _ .. .. .. .. .. .. .. ...... .. .. .. .. .. .. .. .. .. .. .-...q .. .. ..i,. ..: '....:., .... ,.... .... ... .. .. .. .. ., ., .. .. .. i ............: .. .. ..........................L..............i............................ .. ...... .. ...... ... .... ..... ..:..... .. .. . .. ;.. ................... ..<... ..:.. ..::.. I .. ..<... .. ... ....... ....................:...... ... .......... . .. .. 4 ...�� '............ ..... ................. .. ... .......... .... .. .. ! � crL,�ir�r .... ...:. :...... f�l S( kVi PPUBLICFit=HI„T l .i EV"fR(7fVMCNTAfr1`f ` . .. :.. ..:. :. ;..... :.... ................ .. . .. . .....:,......` .. .. .. .. ...:.. .. I .............. ..-...-.-.: . .:.....:. - _.. - .:,. .. ....,.:, .. .. I i DEPARTMENT USE ONLY ,. Application Accepted By Date Atea r I Grant Inspection By Data Pump Inspection By Data i �,. `�Oeitriietlrin'Inspectlon By-'�� Dale Comments: I ACCOUNTING ONLY: AID; FAC; PE CODES FEE INFO AMO NT REMITTEDC /CASH RECEIVED BY DAT PERMITMERVICE REQUEST NUMBER INVOICE 00 y-M2 I` r