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n, � APPLICATION FOR WELLIPUMP PERMIT � r; SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE l� ENVIRONMENTAL HEALTH DIVISION � A� '99� P 0 BOX 38B, 445 N. SAN JOAQUIN ST., STOCKTON, CA 95201-388 (209) 488.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH (Complete In Tdpiieete) PERMIT/SERVICES APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS E IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITITLEE.CHAPTER 8.111 55.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRON QtEN11� [7 JOB ADDRESSfe R i/V I'T a CTT, S P`AAACV EL 3! A/F+�0 0 ( NE OWNER'S NAM -DRESS ' On �ny'�y� NECONTRACTOR I""'� ADDRESSPV-✓✓/` •+r�O- M NE .7 S sLIBCONTRACTO t° ADDREseI57 �7rd lPt7t ^'-NICs sQ_35 IF TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELLN ❑ OTHER ❑ INSTALLATION ❑WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Repair H.P. DEPTH PUMP SET FT, FIRST WATER LEVEL O {TYPE OF PUMP( ', �p�J{n/❑ OUT-OF-SERVICE WELL GEOPHYSICAL WELL• ❑ SOIL BORING� 8 OESTRUCTKIN: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS �LIs A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACKISIZE TYPE OF CASING/STEELIPVC DIA.OF WELL CASING D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATKINIAG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yes ❑Na CONCRETE PEDESTAL BY DRILLFM❑Yes ❑NO S APPROX,DEPTH LOCKING CHESTER BOXISTOVE PIPE S PROPOSED CONSTRUCTION/DRILUNG METHOD: MUD ROTARY AIR ROTARY AUGER CABLP OTHER I HERESY 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 JOA13UIN 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,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUB-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.' THE APPLIC T T C L SIN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 12081469-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. ''ff Sionsd X Titi. PLOT PLAN(Draw tc Scaiel Scala✓L�'to ' 1. NAMES OF STREEfB OR 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, J%W-10{ ApPlDEPARTMENT USE ONLY kation Accepted Sy ( ISI/`5/fVf l�t\ Date r Ares Grout Impamien BY D.a Pump In Pactien By aIs -- Destruction Irrpe"Icn BY_ L.[ i�lN� _ Dne Cornmants: ACCOUNTING ONLY: PJD# FAC# 5 PE CODES FEE INFO AMOUNT REMITTED CHECK#xASH RECEIVED SY -ATE P61MITlSERViCE REQUEST NUK PER INVOICE