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I APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SERV}moi ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA M01-388 (209) 488.3420 r " NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM BATE ISSUED (Complete in TrIPRelltel APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TO CONSTRUCT ANDIOR INSTALL THE WORK DESCRIBED.THIS APPLICATION IS MADE IN COMPLIANCE WITH SAN JOAQUIN COUNTY DEVELOPM^Ei!^T TITLE.C ` 9-1�1�1 3 A THkEI ST DAIjDl3�F •JOAOU�}N��O�UNTY[rL1l , E�SERVICES,ENVIRONMENTAL HEALTH DIVISION. JOB ADDRESSIOR APN# W 56 � t^JQ• ��C/^e`'_Y_LYJ 4�ITY0 r 4��, PARCEL SiZEIAPNi OWNER'S NAME �• ADDRE867 ] U O E CONTRACTOR ' ADDRESS #�PHONE I r / / �J y� 6UB CONTRACTOR /' ADDRESB3233 F/7_W 2/d.C4`` --Lrc�.,y�PHONE r G .��, TYPE OF WELLIPUMP: ❑ NEW WELL 11 REPLACEMENT WELL /L� MONITORING WELL#� G ❑ OTHER I ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSS-CONNECT REPAIRED}'p� ❑ VAPOR EXTRACTION WELL# El New©Repefr HPDEPTH DEPTH PUMP BET FT. tA FIRST WATER LEVEL .� O (TYPE OF PUMP) '.I W I i ❑ OUT-0F-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOIL BORING y , STRUCTION: S ./SJ v /1/r-1 1�M'..l C.' rY1/_r /J� �-f f.�A/r�e�.A /1 C ri� e'[! .✓.' I -._ ': Q nnumarrnees�rsree�r�see� S� INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A � ❑ INDUSTRIAL ❑OPEN BOTTOM A DIA.OF WELL EXCAVATION DIA.OF CONOUC7OR CASING D ❑ DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE TYPE OF CASINGISTEEL/PVC DIA.OF WELL CASING D ' ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL`' t•Pi SPECIFICATION R I ❑ IRRIGATKTNIAG ❑OTHER I` GROUT SEAL INSTALLED'Sy GROUT.BRAND NAME ❑ MONITORING GROUT SEAL PUMPED: ❑'Yns ❑No CONCRETE PEDESTAL BY DRILLER:❑Yes ❑No S. APMOX.DEPTH LOCKING CHESTER BOX/BTOVE PIPE- S I PROP06ED CONSTRUCT10NI'MLLING METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER li 1 HEREBY CERTIFY THAT 1 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:"1 CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKIMAN'$COMPENSATION LAWS OF CALIFORNIA.- CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES i 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 CAUFORNI THE APPLIC NT MUST CALL 24 14OLMS IN ADVANCE FOR ALL REQUIRED I fPECTIONe ATI } .3423. COMPLETE DRAWING AT LOWER AREA PROVIDED. L� ! Signed x � .�lrit� Title. ..�r f r1 Pate I PLOT PLAN Whew to Basial Sols 'I '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,GIVINO DIMENSIONS AND NORTH DIRECTION. -I 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. '! 'j ON THE PROPERTY OR ADJOINING PROPERTY. � I 1 .. ..i. .... ............. .....f........,..,. „.....,.. :. ;.......i. .....f.. ., ., - - -. .. .. .. ., .. i { : .......:.... ...:.... . ....... .„„.,:.,...... ........,.,.....',.., :. ...-...... ., ., .. i ,..,. .:,... ,... ......:... : ... ......; ...... .. .. .. -- -- -. - ., ., .. .. I .... .. ..... ............. �`-- -..... ,-'..-- ...,..,-............. ........:....... .....:. .. :.....,.....,......-:-- r DEPARTMENT USE ONLY ' #e Applfastion Accepted By Date Area }i Grout Inspection By Onto Pump Inspection BY Date a: Destruction inspection By Data ACCOUNTING ONLY: AID# FAC# I r PE CODES FEE INFO AMOUNT REMITTED CHECK#!CASH RECEIVED SY GATE PERMIT/6ERVICE REQUEST NUMBER INVOICE _ I ' ,r