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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERYIC'4 ENVIRONMENTAL HEALTH DIVISION w P 0 BOX 388, 445 N. SAN JOAQUIN ST., STOCKTON, CA 96201.388 ` (209) 468-3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IC4mpbt4 IN Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR APERMIT TO CONSTRUCT AND/OR INSTALLTHE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT/-t TLE,CH` R 9-]115.3 AND TH STANDARDS O SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. T� JOB ADDRESSIOR APN# .s �7f �' —f CITY ;7 + up _ PARCEL SIZEIAPNN OWNER'SNAME PHONE I Cy/'716 . q '7 CCONTRACTORC�o�cp�r�.y�A4,W2��/�r-� i -4- ADDRESS �z��.S� �-'/1l LIC PHONE M./16-' S�./g//S' SUBCONTRACTOR //y�J/� ADDRESS .0'4, O O UC� PHOHEF' /�3 3./N I S TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL MONITORING WELL R ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# J ❑New❑Repalr H.P- DEPTH PUMP SET rr. �FIRRSST WATER LEVEL ITYr O PE OF PUMP} [3OUT-OF-SERVICEWELL 13 GEOPHYSICAL WELL# >�O]L BORING rRu ' Grams 77 /ft? iZ INTENDED USE TYPE Of WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION /2— DIA-OF CONDUCTOR CASING O ❑ DOMESTIC/PRIVATE GRAVEL PACKfSIZE t�f�/P TYPE OF CASiNGISTEELIPVC wG_ _ DIA.OF WELL CASINGA/ ' G ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL �-y� 0''/` SPECIFICATION /1�v��, R ❑ tRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED 13Y_//��z— GROUT BRAND NAME 9MONIYORING GROUT SEAL PUMPED:❑Ye. [IN. CONCRETE PEDESTAL BY DRILLfR,,P�Y. [IN. S APPROX.DEPTH Zs- �S --._ LOCKINC<RESTER BO OVE PIPE S PROPOSED CONBTRUCTIONIWgWNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WOR(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 SUBJECTTO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA.' CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "1 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 APPUCA USY C HOURSN ADVANCE FON ALL REQUIRED INSPE�CyTIyOH,SypT{23 /041 468423. COMPLETE DRAWING AT LOWER AREA PROVIDED. SignedX Tltle PLAT PLAN[Dr—to Seel-)Seale "to I 1. NAME F STREETS R 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. ... : .,... DEPARTMENT USE ONLY Appllwtlan Accepted By ,(u� Date Ar Grout Impaction BY Date �•K-1�J Pump InaPectlan By Destrmtlen Inpeation By Dete L W Comments: . /y 1� rQ AID# FACT 141— PE `tJ T/ ACCOUNTING ONLY: .r P£CODES FEE INFO AMOUNT REMITTED CHECK#ICASH RECEIVED BY DATE PERMITISERVICt REQUEST NUMBER L-(C INVOICE l , l0 `rte t flLE COPY