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!M. I, U-a APPLICATION FOR WELLIPUMP PERMIT SAN JOAQUIN COUNTY PUBLIC HEALTH SER ENVIRONMENTAL HEALTH DIVISION k RO, BOX 388, 304 EAST WEBER AVENUE, STOCKTON, CA 96201. 88 (209) 468.3420 ` NON-REFUNDABLE PERMIT EXPIRES'I YEAR FROM BATF ISSUED IComplsts in Trlplkst6l APPLICATION IS HERE BY MADE TO THE SAN JOAQUIN COUNTY FOR A PERMIT TQ CONSTRUCT ANb/VR INSTALL THE WORK DESCRIBED,THIS APPLICATION to MADE IN COMPLIANCE WITH SAN ' JOAQUIN COUNTY DEVELOPMENT TITLE,CHAPTER 8-1116.3 AND THE STANDARDS OF 8 JOAOVIN COUNTY PUBLIC HEALTH SERVICES,ENVIRONMENTAL HEALTH DIVISION. ' JOB ADDRESS/0101 ARV# 'I t, CITY PARCEL 81ZElAPN# OWNER'8 NAME t ADDRESS d CONTRACTOR . 9r !•i/' . F ADDRESS LIC# PHONE d.�-[FO GC CA BUB CONTRACTOR S � '' ADDRESS LIC PHONE d r OF WELLIPUMP; ❑ NEW WELL ❑ REPLACEMENT WELL I' �iIONMORINq WELL/,,(r'=(� ❑ OtHER ❑ INSTALLATION ❑ WELL SYSTEM REPAIR ❑ CROSSCONNECT REPAIR pW �- ! � ❑ VAPOR EXTRACTION WELL! ❑Now❑Repair H.P. DEPTH PUMP SET FT. FIRST WATER LEVEL O I IT YPE OF PUMP► ❑ OUT-OF-SERVICE WELL ❑ GEOPHYSICAL WELL# ❑ SOILIBORING g i RUCTION: �r2t I j F ��I--NyyTENDED USE TYPE OF WELL CON TR TION 6PMIRCATION6 *A U INDUSTRIAL 11 OPEN BOTTOM ! DIA.OF WELLhEXCAVATION DIA.OF CONDUCTOR CASINO p DOMESTIC/PAIVATE ❑GRAVEL PACKISIZE 1 TYPE OF CASING/STEEUPVC ' DIA,OF WELL CASING p ❑ PUBLICIMUNiCIPAL 0 7 DRIVEN DEPTH OF GROUT SEAR 8PECIFICATION .R ❑ IRRIGATION/AG ❑OTHER GROUT SEAL INSTALLED BY r GROUT BRAND NAME E , MONITORING GROUT SEAL PUMPED: ❑Yr ❑No CONCRETE PEDESTAL BY DiULLER:❑Vaa ❑Ne � S APPROX.DEPTH LOCKING CHESTER BOX/STOVE RPE s PROPOSED CONSTRUCTIONMRILLINO METHOD: MUD ROTARY AIR ROTARY AUGER CABLE OTHER I HEREBY CERTIFY THAT I HAVE PREPARED TH18 APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES,STATE LAWS,ANO RULES'ANO REGULATIONS OF THE SAN JOAQUIN COUNTY, HOME OWNER OR LICENSED AGENT'$SIGNATURE CERTIFIES THE FOLLOWING:'I CERTIFY THAT IN THE PERFORMANCE OF THE WOW FOR WHICH THIS PERMIT IS ISSUED,I SHALL NOT EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR 8UB-CONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: 'I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED,I SHALL EMPLOY PERSONS SUBJECT TO WORKMAN'S COMPENSATION LAWS OF CALIFORNIA," APPLICANT T CALL M HOURS IN ADVANCE FOR ALL REGURtEI INSPECTIONi AT{ 4SS-3422, COMPLETE DRAWI AT LOWER AREA PROVIDE . Slpned X r Tltl I _ r t Date p _ PLOT PLAN(Draw to 64414)Beale 'to T 0 NAMES OF STREET$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. p 3.':DIMENSIONED OUTLINES AND LOCATION OF ALL EXISTING AND PROPOSED i' S. LOCATION OF WELLS WITHIN RADIUS OF ONE HUNDRED FIFTY FT,. 'STRUCTURES,INCLUDING COVERED AREAS SUCH A8 PATIOS,DRIVEWAYS,AND WALKS.. h ON THE PROPERTY OR ADJOINING PROPERTY. .. ... .. ., ., .. :+ _ .. I Y .. .. .. .. :. .....,. .... ....,. ... .... .. .. ' .. .. ., ;} �I - �-�r -- �+yr�'�,�*�r.� e N'•':. :t:a•.M.�.�..�or :. •.:ir..n.'-'rrir►�+0i' Md it r DEPARTMENT USE ONLY J�j�� Applieatfen Aeeepted Sy 1 I l r - bate_10-251R,' �� Area Grout Iropaetlon By Date_ Pump InspectloIn By Date } Destruction inspection By `' - k Data 0 Comments- ACCOUNTING omments L ES I .r ACCOUNTING ONLY: AlD# FAC# y PE CODES FEE INFO AM T REMITTED CHECK#ICASH RECEIVED BY DATE PERMIT16ERVICIR REQUEST NUMBER INVOICE r If q 6 , '� :l n