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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERV,--S ENVIRONMENTAL HEALTH DIVISION P,O,BOX 388,304 EAST WEBER AVENUE,STOCKTON,CA 9MI,3 88 (209)466.3420 NON-REFUNDABLE PERMIT EXPIRES I 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/--1115.311 THE STANDARDS OF SAN JOAQUIN COUNNTTYY�PUURUC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APN# (3 3//'�� tg(`4j C T�/�(1 CITY J 1 U(' ��y \ PARCEL SIZE/APN# OWNER'S NAME..gj\,1MY\ L :5:kk-k0 V\ ADDRESS PHONES CONTRACTORTSV\�j LI_(1 130��y] �� S_Ovuci 4405 -Z SUR CONTRACTOR ADDRESS N oS�G�- CS�� 3 LIC# PHONE# TYPE OF WELLIPUMP: ❑NEW WELL ❑REPLACEMENT WELL ❑MONITORING WELL# ❑OTHER _ ❑INSTALLATION ❑WELL SYSTEM REPAIR ❑CROSS-CONNECT REPAIR ❑VAPOR EXTRACTION WELL 0 J (TYPE OF PUMP 13New 13Rep.lr H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 6 ❑OUT-OF-SERVICE WELL ❑OEOP/YSICAL WELL# SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OFWELL CONSTRUCTION SPECIFICATIONS A 11INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑DOMESTIC/PRIVATE 11GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D ❑P/BUC/MUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R 11IRRIGATION/AG 11 'OTHER GROUT SEAL INSTALLED BY I�11,10 GROUT BRAND NAME E ❑MONITORING GROUT SEAL PUMPED:[I y- ON. CONCRETEPEDESTALBYDRILLER:❑Yw []No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PPE S PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER 1 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 IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CAUFORNIA.'CONTRACTOR'S HIRING OR SUBIONTRACTING 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 CAUFORNIA.' IE APPU ANT MUST CALL 24 H OURS IN ADVANCE FOR ALL REQUIREDININSSPECTIONS AT 120111 4eSJ423.COMPLETE DRAWING AT LOWER AREA PROVIDED. Signal X TIV. 7i a L 1_�`� D.t. R/a�l9rS" 4Rywv�Low_-__ PLOT PLAN(Or.w to Scots)"a to 1.NAMES O 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, /�yL/J ,^//) DEPARTMENT USE ONLY Applie.tlon Accepted By / /1` / '�`!e� Oete Grout I-pectlon By ONe Pump.-'-"—By D.te Dwlruetlon Irspecdon By D.te ' Comment. - ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK//CASH RECEIVED BY DATE P91ANT/SERVICE REQUEST NUMBER INVOICE 15 SW-3--5 - 00