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APPLICATION FOR WELLIPUMP PERM SAN JOAQUIN COUNTY PUBLIC HEALTH SER ICES ENVIRONMENTAL HEALTH DIVISION RO, BOX 388, 304 EAST WEBER AVENUE, STOCKTON. CA 9SM-388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED (Complete in Triplicate) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT AND/OR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. /6 y <Ic�s JOB ADDRESS/OR//APNM L 1i3ay o%,t./s �'pA,tJp ,�Q LQV/SE x}1(6 CITY PARCEL SIZE/APN�1_I9 ^/�O-�( OWNER'S NAMEZ_,dbY gL CA4f L"Q;QQ ADDRESS �O O� yL Ot/�r.S PHONE X CONTRACTOR1�/Q.-jr-,C- r�/2✓1` ADDRESS OZ V*IL OL�.eI//N .2 o �,CIiJJ� UC# PHONE# 1Y5-6b'/1) SUB CONTRACTOR /�-�,� (n/-/_/ ,�(/ ADDRES62Q2y tl 61%W-17-7e (ig y LIC# 3 7/ 560 PHONE#Y.[2-76 7.0 TYPE OF WELUPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL WMONFTORING WELL Or ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ❑ (TYPE OF PUMP) w 11NeRepair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL 0 ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL+1 ❑ SOIL BORING g ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION 1,3 �/ DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PR7e IVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEFUPVC .SGf DIA.OF WELL CASINO l „ D ❑ PUBLIC/MUNICIPAL ❑DRIVEN DEPTH OF GROIfT SEAL SPECIFICATION ! � R ❑ IRRIGATION/AG ❑ reap-1,C5' GROUT BRAND NAMEsrG-e✓OTHER GROUT SEAL INSTALLED BY (- e (�h� . e ��7-y-� es ❑ ❑ MONITORING GROU, SEAL PUMPED: OO YNo CONCRETE PEDESTAL BY DRILLER:❑Yea rC [IN. S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CON$TRUCTIONIDRILLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$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,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S,COMPENSATION LAWS OF CALIFORNIA.' dOXNIA.' T APPU AI{1'�8Y C/1L1/2gV HOyRB IN ADVANCE FOR ALL REQUIRED % PEC TION$L�T�(��1468-3423.1COMPLETE DRAWING AT LOWER DA:AREA��ID� Titl 1 C/ L (4/ ( PLOT PLAN (Draw to Scale)Scale /!-r"J� C'to , L 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 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. L�G/S y owEars �aeD 20 - D/6 1' V/'y./`-' DEPARTMENT USE ONLY �j Appllcetlon Accepted Sy F./°V Date -71/1 /� Area Grout Impaction By Date Pump Inspection By Date Destruction Inspection By Date Comments: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE a � 61