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APPLICATION FOR WELLIPUMP PERMIT y-AN JOAQUIN COUNTY PUBLIC HEALTH SER> ENVIRONMENTAL HEALTH DIVISION ' P 0 BOX 388,445 N. SAN JOAQUIN ST., STOCKTON, CA 95201.388 (209) 488-3420 # NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1comPleta in Triplicate) I APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTAL(THE WORK DESCRIBED,THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPP�T�E1R 9.1115.3 AND '��THE (�STANDARDS OF SAN JOA IN COUNTY PUBLIC HEALTH`SERVICES,ENVIRONMENTAL HEALTH DIVISIONS} h JOB ADDRESSOR APN# I10I•V"7 S Ot'j/�j0- - `` [ )2V P tt t4j V 1 ZV�m. � -L„�/V` `' PARCEL 517_ElAPN3 OWNER'S NAMEO—tTY� l.J�iV .'t"1�t1li.�i ��A 9_r RES6_F O �-+O ZgY 1�`�� f•a 220 PHONE CONTRACTOR__V zrlhy ~R i.4�. . '�(,,[ s hr 45'� PHo ADDRESS ��p�/J,/� - SUB CONTRACTOR .— C.E�( —ADDRESS ys FAY 0�L��PHONE, TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER I ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ❑New❑Repair H.P. DEPTH PUMP BET FT. FIRST WATER LEVEL O I ffYPE OF PUMPI ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL s )<SOIL BORING ` B ❑DESTRUCTION- INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS q' 0 INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D 11DOMESTICMRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEE._,C DFA,OF WELL CASING D ❑ PUBLIC/MUNICIPAL ❑ OVEN DEPTH OF GROUT SEAL SPECIFICATION I Ix R ' IRRIGATIONIAG THER GROUT SEAL INSTALLED BY GROUT BRAND NAME E MONrrORING 4561-�L f�y��j��-, r GROUT SEAL PUMPED: ❑Yea No CONCRETE PEDESTAL BY DRILLER:❑Yea ❑No S (APPROX.DEPTH f 4' I ' �4pO �I �� LOCKING CHESTER BOXISTOVE PIPE S. PROPOSED CONSTRUCTIONORIWNO METHOD: MUD ROTARY AIR ROTARY AUGER GABLE OTHER s 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:"i CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 16 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FO G: . ERTIFY TH IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF i CAUFD IA T ANT T CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT(20014683623. COMPLETE DRAWING AT LOWER AREA PROVIDED. (� Signed X M. PLOT PLAN (Draw to 606181 Sole `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. 1 ..............i.......;......i..............i.......'.... .. -- --- .. .. .. - .. .. .. - .. .. .. .. .. .. .. .. .. .. - .. .. ...... .. .. .. - .,.., .... ..i. -- .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. j I ......i.............i.......>......i.............:......:;..... ., .. .. .. .. .. .. .. .. ......... .. .. .. .. .. .. .. .. -- .. .. .. .. .. .. _ .. ....... _. ..,..i..., .. .. ME ........ -- ..... � NT. - ......■>t� '......... <..... ............ CEIVED . .. :.. . QLIIN .. ..:.. ... . .. f 'RML-It i->'EiiSFRMES NVIRONP�4E{Vfi ... .. : .................. :...........:....... . . - ' DEPARTMENT USE ONLY I Application Accepted By Dat Arm Grout Impectlon By Date Pump impaction By Data --- — astructlon Inspection'By _ F •F - Date Comments: i t t ACCOUNTING ONLY: AID# FAC#' PE CODES FEE INFO AMOUNT REMITTED C !CASH RECEIVED BY DATE PEJVMITISERVICE REQUEST NUMISE R INVOICE 1 l 411n