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APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SEK ENVIRONMENTAL HEALTH DIVISION P.O, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 95201 X88 (209) 468.3420 NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED IComplatu In TripRats) APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE!N COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPMENT TITLE.CHAPTER 9-1115.3 AND THE STANOARDS'OF SAN QUI O MY PU LIC 11qLTSERVICES,ENVIRONMENTAL HEALTH DIVISION. < JOB ADDRE88fOR APN# h PARCEL SIZFJAPN# '4, , OWNER'S NAME 10 h�ll ADDRESS LI /t� ONE )) CONTRAC1911,4 TOR [/ ADDRESS /tJO ups # PH NE7`,ryt 11 SUBCONTRACTOR ri ADORERS LICO —f- !.2 PHONEI �o !— �k t, TYPE OF WELLLPUMP: ❑ NEW WELL © REPLACEMENT WELL • �NITORINO WELL#,� ❑ OTHER i ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR ❑ VAPOR EXTRACTION WELL# ❑New❑Repair H.P. DEPTH PUMP SFT FT, r FIRST WATER LEVEL `• 0 (TYPE OF PUMP) �-yI'J -O❑ OUT-OF-SERVICE WELL Cl GEOPHYSICAL WELL# ❑ BOIL�SORING -ti' B �FBESTRUCTION: -r//I..f •( i /Z(_(� /'ttC INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATION& A ❑ INDUSTRIAL ❑OPEN BOTTOM DIA.OF WELL EXCAVATION DIA.OF CONDUCTOR CASINO D 1 ❑ DOMESTICJPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASING/STEEUPVC DIA.OF WELL CASINO + D1401 i ❑ PUBLICIMUNICIPAL ❑DRIVEN �, DEPTH OF GROUT SEAL SPECIFICATION R i 11 IRRIGATIONIAG ❑OTHER GROUTSEAL INSTALLED BY GROUT BRAND NAME E ' ❑ MONITORING GROUT SEAL PUMPED: ❑,Yee [IN. CONCRETE PEDESTAL SY DRILLER:❑Yee ❑Ne S, APPROX.DEPTH LOCKING CHESTER BOXISTOVE PIPE S PROPOSED CONSTRUCTION/DRILLING METHOD; MUD ROTARY AIR ROTARY ? - AUGER CABLE OTHER w 1 I' I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK:,WILL BE DONE'W 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:'1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT 18 ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOVANG: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN-41 COMPENSATION LAWS OF CALIFORNIOtnHE APPLICANT MUST CALL M HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS AT"14411111144" COMPLET DRAWING AT LOWER AREA PROVIDED. Signed%--r= f��" Titli 0 .L 0 r Y Date - PLOT PLAN IDraw to Boole)Bc o 'to x 1. NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 4. LOCATION OF HOUSE SEWAGE DISPOSAL SYSTEM OR PROPOSED R. OUTLINE OF THE PROPERTY,GIVING DIMENSIONS AND NORTH DIRECTION, EXPANSION OF SEWAGE DISPOSAL SYSTEMS. 3, DIMEN8IRNED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY Fr i STRUCTURES,INCLUDING COVERED AREAS SUCH AS PATIOS,DRIVEWAYS,AND WALKS, '. ON THE PROPERTY OR ADJOINING PROPERTY. ......,... ..,....., ..... .. . .. .... ....... . .. ., -- .. .. ., ., .. .. ... .,.. .., ., _ ... _ . .... .... :..., - ...-. ... .. .. ..:. .. r.. .-.r... . ; : : [ - F ..L....,.....r ._ .-- .. -. -. _.i. .... .,. .,.. `. .. _ . t '�--��:Y.cGu:'�i. .-. ....�xa" fir". --�.s.�4 Y :_-. ...: u'.:.0 t':.�' ..�. .ti.�.: .1J•' _ I• DEPARTMENT USE ONLY Application Accepted By�:l 'n j .�(p Date- Area '>` il Grow Inepectlon BY Date Pump Inspection By Date t - Destruction inspection By a Date - Commente• ACCOUNTINO ONLY: AID# FAC# PE CODES FEE TNFO AMOUNT REMITTED CHECKSMASH RECEIVED BY DATE PLTfiMITISERVICE REQUEST NUMB R INVOICE ,Ito oto F42