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APPLICATION FOR WELLIPUMP PERMIT SAN JOAIIUIN COUNTY PUBLIC HEALTH SER' 'S ENVIRONMENTAL HEALTH 01VISION r.r1 P.O. BOX 388, 904 EAST WEBER AVENUE, STOCKTON, CA MMI- 8 (203) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED {Complete in Triplieits) 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,CH`' 7y�E,R 9-111 S. AND THE STANDAgrpg,�O/F►}SAN JOA UIN COUNTY PUBLIC HEA(L1T/Hy SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSOR APNar •'�Tr �� ' '"/t (� �Cr�S � � ITY�'.!� � +l"'1 V) PARCEL SIZEIAPN/ OWNER'S NAME sq/1 r-j v'Yl G-tn,., ADDRESS '-ry`yv�` '1 �J 1"/�� 1 PHONEX (j/ OWNER'S CONTRACTOR rt&;6- �G ADDRESS.IVY 6 IGA'3''�!. J".'>r VS}�y.1 i � Q�I JI PHONE¢I '�Z[�-CA SUB CONTRACTOR ""Q {` •/l ADDRESS! 'V- �� 6�b(/,v1 LICA O'4-3q PHO, I_'3111-T 3 n TYPE OF WELLlR1MP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL• M�� ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL/ J ❑New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p {TYPE OF PUMPI r JF &'�Mme't 13 OUT-OF-SERVICE WELL j,, ❑ GEOPHYSICAL WELL# ❑ SOIL BORfNG B 'A DESTRUCTION: fe- ( 6� f `W INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN$OTTOM DIA.0 F WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ OOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASFNOISTEELIPVC /"�� ... VIA.OF WELL CASINO Z-r' D 11PUBLICJMUNICIPAL 11 DRIVEN DEPTH OF GROUT SEAL ty SPECIFICATION R ❑ IRRIGATIONIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL SY DRILLER:❑Yw [IN. S APPROX.OWTH LOCKING CHESTER SOXMTOVE PIPE g PROPOSED CONSTRUCTIONIDPoLUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOW WILL BE DONE IN ACCORDANCE%MTN SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'$SIGNATURE CERTIFIES THE FOLLOWING:•1 CERTIFY THAT IN THE PERFORMANCE OF THE MW FOR WHICH THIS PERMIT 16 ISSUED,I SMALLNOTEMPLOY PERSONS SUBJECT TO WORKMAN'S COMP1ENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFYMHAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKM�AN'i COMPENSATION LAWS OF APPLI �I11 ADVANCE FOR ALL REOUIRED1INNSPECTIONr4 AT 122�0p111114�-003422. COMPLETE DRAWING AT LOWER AREA PROVIDED. p RI , TIt1e.--V' 1 •. 5'"`�t'I Data 1(7-1 O C I MUST CALL 24 HOURS IN SI nad X__ ._.._. . „ ,.,.. PLOT PLAN IDraw to Scala)Scale to _1. NAMES OF STREETS OR ROADS NEAREST TO OR SOUNDING 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 OUTLINF,S 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. E. DEPARTMENT USE ONLY Applloation Aeeooted By �__ • ,,, __ Date [ U Area Grout Inspection By Date Pump hupectlon By Date Deatrtrctlon Inspection By •^"�"'t q Date Comment• �' _5- -/ ACCOUNTING ONLY: AIDE FACE PE CODES FEE INFO AMOUNT REMITTED CHECKO CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE