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APPLICATION FOR WELLIPUMP PERMIT _AN JOAQUIN COUNTY PUBLIC HEALTH SERVIL,_ , 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. JOB ADDRESSOR APN#/6 7/ l7 UWL/9�VU /�D, l �•^ J �4�f GJ T J CITY z,-V77/v&0,4' PARCEL.SSIIZE/APN# OWNER'S NAME L�'«/.UC/V%/'V L L��/✓f/�K�[, �O�P ADDRESS '�0 ,`J Gx 71z0 Nirl/>:CJ�G/�L t:-};/1/r PHONE# CONTRACTOR %RE.4TEK-(:fZ',0? .202 rf4 .0—ee411A1 "A-1 ADDRESS LIC• PHONE O SUBCONTRACTOR ADDRESS x.36 S W/4 WAM LK;#Si.2 2 6 8 PHONE TYPE OF WELL/PUMP: ❑ NEW WELL ❑ REPLACEMENT WELL ❑ MONITORING WELL# ❑ OTHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIR ❑ VAPOR EXTRACTION WELL# (TYPE OF PUMP) 11New 11 Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL p �� 11OUT-OF-SERVICEWELL 13 GEOPHYSICAL WELL# Q SOIL BORIN g ODESTRUCTION: % .PEM/[_ G/cDUT INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASING D ❑ DOMESTIC/PRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEL/PVC DIA.OF WELL CASING D ❑ PUBLIC WUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY GROUT BRAND NAME E ❑ MONITORING GROUT SEAL PUMPED: ❑Yes [IN. CONCRETE PEDESTAL BY DRILLER:❑Vee []No S APPROX.DEPTH LOCKING CHESTER BOX/STOVE PIPE 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 REGULATI OF THE SAN JOAQUIN COUNTY. HOME OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THI RMIT ISI ;UED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSA71ON LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES T FOLLOWING:)-Al CERTIFY THAT IN THA PERFORMANCE F THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CA ORNIA.' T PPU A MVS 24 HO IN D ANCE R ALL REQUIRED INSPECTION$AT 12091 4694423. COMPLETE DRAWING AT LOWER AREA PROVIDED. Sloned X �t.� Title 2�� .. Data / — —�� 1 �^1 b PLOT PLAN(Draw to Scale)Scala V 'to 1. NAMES OF STREETS OR DS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED 2. OUTLINE OF THE PROPS ,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. ....;.....:.._.. .....:........................................... ..... .. .. .. .. .. .. .. .. .. .. ......... .. .. .. .. .. .. ............. .. .. ...:. o /� DEPARTMENT USE ONLY Application Accepted By l CIA-- — Date `Z —v�D - L' At" Grout Inspection By Date Pump Inspectlon By Date Destruotlon Inspection By Date Comments: ACCOUNTING ONLY: AID# FAQ# PE CODES FEE INFO AMOUNT REMITTED CHECK#/CASH RECEIVED BY DATE PERMIT/SERVICE REQUEST NUMBER INVOICE