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APPLICATION FOR WELLIPUMP PERMIT N #4 SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICIN ENVIRONMENTAL HEALTH DIVISION P 0 BOX 388, 445 N. SAN JOAOUIN ST, STOCKTON, CA 95201.388 (209) 402.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ICampltts is Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WOR(DESCRIBED,THIS APPLICAIMN IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER `}9-11 5.3 AND T=HS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR{rAPN#L L h y o[^�) CITY ��ck—" PARCEL SiZFlAPNX ^�-` '^ OWNER'S NAME..�.I!�' N C1c) IS �� ADDRESS tA,_ r n PHONE IBX !^ ]l.J_G_T� CONTRACTORS_ C,n1`:1�iWA fr T�\ i 1fJT�+Q/J ADDRESS LIC&3 J UC/ t PHONE i �7 0 SUBCONTRACTOR _ A1C V l�1 ZIA ADDRESS 7Cd[�9 V •r/�W it t`� 'o._ LIC n nw-NE T1� / IIAfs TYPE OF WELLJPUMP: D.NEW WELL ❑ REPLACEMENT WELL yS,MONITORING WELL+► I ❑ OTHER INSTALLATION ❑ WELL SYSTEM REPAIR ✓❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELLO4J New❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O TTYPE OF PUMP) ❑ OUT-OF•SERVICE WELL ❑ GEOPHYSICAL WELL M ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION CIA,OF CONDUCTOR CASING ❑ DOMESTicimvATE ❑GRAVEL PACKISIZE TYPE OF CASINGISTEEUPVC DIA.OF WELL CASING F ❑ PUBLICIMUNICIPAL ❑ RIVEN DEPTH OF GROUT SEAL �y-/UCJ SPECIFICATION R \1❑ IRRIGATION/AG ZHER GROUT SEAL INSTALLED BY�/'y—G � GROUT BRAND NAME E K] MONITORING ,'1 GROUT SEAL PUMPED: 13 Y. El No CONCRETE PEDESTAL BY DRILLFR:❑Y— [IN. S APPROX.DEPTH l Zv LOCKING CHESTER BOX/81"VL"?IPE� S PROPOSED CONSTRUCTION/DRILLING METHOD: MUD ROTARY AIR ROTARY AUGER_CABLE OTHER 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 IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPBJSAT30N 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 T APR/CANT UI MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 120!1 45t,3423. COMPUTE DRAWING AT LOWER AREA PR VIDEO. T11-7 ti Y� p--� n:sa rz, ' _- Signed x Y wt. - - .I 61 PLOT PLAN IOraw to Scale)Scale � "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 6. 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. See -� k,� t t Arw:A I fa a 3�wV'^l N anti DEPARTMENT USE ONLY I ^r ApPllutlon Amepted BZj y L Data 1 v Aroe�_ Grout Inspection BY Date Pump Inspection By Date Destruction Irwpaetion By Date Comments ACCOUNTING ONLY: AIDS FACS PE CODES FEE INFO AMOUNT REMITTED CHECKS/CASH RECEIVED BY DATE PEF"T/SUMCE REQUEST NUMBER INVOICE oa l 5 ?sv