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. APPLICATION FOR WELLIPUMP PERM SAN JOAQUIN COUNTY PUBLIC HEALTH S „ ES ENVIRONMENTAL HEALTH DIVISION P,O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201.388 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 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. 8/4GK f JOB ADDRESSIOR APN#_�C- 77 7 A1ow(_4n/V JPS ✓�SMQLo j) CITY /iO PARCEL SIZE/APN#lli5'1dO A?. S -05 OWNER'S NAME ✓' . //y//nL U/ ADDRESS �& 777 l7Lx„�y^/(� ,�� PHONE# ;10CONTRACTOR �-47,!. -Ceq —ADDRESS-?02 (/4I v4" A7' LIC# PHONE# �J,y 3-G2I0 SUBCONTRACTOR LLr¢,ei(' `(ICLC 1/16 ADDRESS202`/ E. G-17*,ereoe w9y uc# 37/56V PHONE#Y42-7i26 TYPE OF WELLIPUMP: ❑ NEW WELL ❑ REPLACEMENT WELL A MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ❑New 11Repair N.P. DEPTH PUMP SET FT. FIRST WATER LEVEL D (TYPE OF Ft/MP) ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL R ❑ SOIL BORING R ❑DESTRUCTION: INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS a A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEELIPVC -5 74C�G l DIA.OF WELL CASING�j Sl u D ❑ PUBLIC IM UNIC IPAL ❑DRIVEN DEPTH OF GROUT SEAL 7'4.61.I c (� SPECIFICATION `S—,V,/C�'/ s/�LyQ/�f�►Lff�KT R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY CL.'¢,eK GROUT BRAND NAME lNEST�,&/ E ❑ MONITORING GROUI SEAL PUMPED:➢LJ Yes ❑No CONCRETE PEDESTAL BY DRILLER:❑Yr 1111 ❑No S APPROX. DEPTH LOCKING CHESTER BOX/STOVE PIPE S PROPOSED CO NSTAUC TIO N RNtl LUNO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT 114AVE 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 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.', t!E A T CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT 1209)469-3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Slpned X � � Title / �-�' /L. X/'ti �. Date /'j PLOT PLAN IDraw 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. - Lo,.isr �3YC o"C v ... (1 �. _ X _ .... ........... II DEPARTMENT USE ONLY ^f Application Accepted By ' Dete 1 Area Grout Inspection By Date Pump Inspection By Date Destruction Inspactlon By Date Comments: ACCOUNTING ONLY: AID# FAC# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE