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APPLICATION FOR WELLIPUMP PERMIT�,--•� USAN JOAQUIN COUNTY PUBLIC HEALTH SERL� ENVIRONMENTAL HEALTH DIVISION ,'FP.O. BOX 3M 304 EAST WEBER AVENUE, STOCKTON, CA 95 I-m i y (2091488-3420 j NOM-REFUMDABLE PERINIT EXPIRES f YEAR FRDM DATE lSSUEU I Komplett in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE/,CHAPTER 9.1 115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESS/OR APNN f l CITY OWNER'S NAME„ 5 ADDRESS �9 ONE �Z�j P SEL Si2ElAPNl 91 CONTRACTOR ADDRESS I 1 .I �k 9 PHONE OF I� SUB CONTRACTOR LJ t?� ��1 �I!�►� ADDRESS i �} TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL I ' ' OTHER ❑ INSTALLATION 1 WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR El VAPOR EXTRACTION WELL,f f J I _ N.❑RepairH.P. DEPTH PUMP SET FT. FIRST WATER LEVEL (TYPE OF PUMP) O ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL 0 EV111,11-BORING 8 ❑DESTRUCTION: � s � - INTENDED USE TYPE OF WELL, CONSTRUCTION 8PECIFICATIONt I ❑ INDUSTRIAL ❑OPEN BOTToM p DIA.OF WELL EXCAVATION 011A.OF CONDUCTOR CASING O s ❑ DOMEBTIClPRIVATE ❑GRAVEL PACKISIZE TYPE OF CASINGI6TEEL/PVC DIA.OF WELL CASING - O 11 PUBLK%IMVNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL 4 SPECIFICATION h R 1:1IRRIRATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME �) •' 11 MONITORING E I GROUT SEAL PUMPED: ©Yea Ly►1e CONCRETE PEDESTAL BY DRILLER;❑yw ❑Ne S f APPROX.DEPTH .r� LOCKING CHESTER BOXlSTOVE PIPE S +f PROPOSED CONSTRUCTIONlDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER- - I HE9EBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH BAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND I - REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:"I CERTIFY THAT IN THE PERFORMANCEIOF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S.COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR BUB-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.. TT,HE`r pfJjpJC�ANT MUST CALL k4 HOURS.IN ADVANCE FOR ALL REQUIREPEC D INSPECTIONS AT 12091448-3422. COMPLETE DRAWING AT,LOWER A >nD Signed X. �/�+_ A1.�iw1 Titla bat PLOT PLAN(Drsw to Swlel Soria 'Ilk- 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 B. 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; - F ....... ... . ,- 1,j .... 0315 . . ... . .. .... :.. ..... ... .. .. . . ........'...:....... .:. .. .. .:. .. . ..:..... . . . .. i - i .,.-:, -..,.,.... t........... ....... .. i. ... _ .. �,s.w -u 7.,�.�,r��`.+r ' ��...�:_ '*'"•r�•-!Y��Fe .�r..;:^r. - t P DEPARTMENT USE ONLY Det, Application Accepted By 1 ' + 1 /v/t� l � l'� 6 Area Grout Inspection By Dote� Pump Impaction By +Dole Destruction Impaction By Gate Comments: n i. ACCOUNTING ONLY: AIDS FAC/ PE CODES FEE INFO AMOUNT REMITTED CHECKIICASH RECEIVED BY DATE PSRMIT/SERVICE REQUEST NUMBBt INVOICE t3S o €AT`4 s !� 0091 -7 J: