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y APPLICATION FOR WEL11PUMP PERMIT } SAN JOAQUIN COUNTY PUBLIC HEALTH SERV:... ENVIRONMENTAL HEALTH DIVISION P.O. BOX 388, 904 EAST WEBER AVENUE, STOCKTON, CA SMIM M d2091 468.3420 NON-REFUNDABLE PERMIT EXPIRES_1 YEAR FROM DATE ISSUED ICompMts in Tripmats) 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 JOAOUIN COUNTY DEVELOPMENT TITLE,CHAPTER 9-1115.3 AND THE STANDARDS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION, JOS ADDRESSIOR APNf CITY PARCEL SIZEIAPNi S' OWNER'S NAME ADDRESS/ ls' 0 E Of CONTRACTOR ADDRESS I PHONEI SUB CONTRACTOR ,F ! 6*"n. ADDRESS 3 -CrLSr�f9'79 PHONE r F TYPE OF WELLA'UMP: ❑ HEW WELL E3 REPLACEMENT WELL �'- --IOIONITORINO WELLf��.,�_7.'q! ❑ OTHER 13 INSTALLATION 13 WELL SYSTEM REPAIR 11CROSS•CONNECT REP-t—AII-- _ 77�b VAPOR EXTRACTION WELL 0 J t ❑New❑Repair H.P. DEPTH PUMP SET ITYPE OF PUMP) ��/^a' FIRST WATER LEVEL b '` C 13OUT-0SERVICE WELL ❑ GEOPHYSICAL WELL s_ Pwl� ❑ BOIL BORING g �. BTRUCTION- INTENDED USE TYPE OF WELL CONSTRUCTION SPECIFICATIONS A ❑ INDUSTRIAL ❑OPEN BOTTOM DfA.OF WELL EXCAVATION I DIA.OF CONDUCTOR CASING D © DOMESTICIPRIVATE ❑GRAVEL PACK/SIZE 1 TYPE OF CASING/STEEL/PVC 1714,4)- DIA.OF WELL CASING D ❑ PUBLICIMUNICIPAL ❑DRIVEN DEPTH OF GROUT SEAL SPECIFICATION R ❑ IRRIGATION/AG [3 OTHER GROUT SEAL INSTALLED BY:' GROUT BRAND NAME E 1 ❑ MONfTOR1N0GROUT SEAL PUMPED: ❑Yea ❑No CONCRETE PEDESTAL BY DRILLER:[3Y. ❑Ne S ! i APPROI[.DEPTH y _ S4 LOCKING CHETER BOX/STOVE PIPE .S I PROPOSED CONSTRUCTIONIDAILLING METHOD: MUD ROTARY AIR ROTARY . AUGER CABLE OTHER h ' I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL.BE DONE IN ACCORDANCE WITH BAN 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 WOW 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 18 ISSUED,1 SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF 1 CALIFORNIA." THE APPLICANT MUST CALL 24 HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS,AT 120014".242W. COMPLETE DRAWING AT LOWER AREA PROVIDED. f.: Slpned X Title 17 two T PLOT PLAN 1Draw to Soale)Soale 'to RO ' 1, NAMES OF STREETS OR ROADS NEAREST TO OR BOUNDING THE PROPERTY. 's 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 OVTUNFS 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. ..-...,... ,.....:..... ... ... . .., - .... - Ar Y 4 .......................... ............... - ........... ...........- ..:... :.... ....L.. ....,. ...I. ..,.:,....- yy . :......: ........ . ...... ....... .:..-.. . ............... ....... . ., E ...... ............. ..........,.-. .. :. .. --..,.. ., ., .. .. .. m z ....................... i.. .., -- - ..5., .. .:,.. ........... ..... ...... ......... ........ .... r 4> ......... ........... ............ ............ ............ ....... ............ ........... .................. .......... ................ ............ ............... ..................... .......... ............... .... ............. ....... m 1 DEPARTMENT USE ONLY Application Acoopted B'?OY�� '7 Date / Area' ✓✓Y Grow Inspection by Date .''Pump Inspection By Date 4 Destruction Inspection By Date Comments: � I ACCOUNTING ONLY: AIWR FAC/ j PE CODES FEE INFO AMOUNT REMITTED CHECK!/CASH RECEIVED BY DATE P14RMITISERVICE REQUEST NUMBER INVOICE ✓ � � r2G✓' J� D I V l